Share your information with Cheryl Cooper

Cheryl Cooper

Élevé Experiences Travel Agency

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h1" label="Group Cruise"/>&#13;
		<field type="header" subtype="h1" label="EXPLORA III Caribbean Opulence Group Cruise, March 14-21, 2007"/>&#13;
		<field type="header" subtype="h2" label="Traveler Information"/>&#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="header" subtype="h2" label="Important Dates"/>&#13;
		<field type="date" label="Birthday" name="birthday" className="form-control"/>&#13;
		<field type="text" required="true" label="Primary phone number" name="phone-number" 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="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" 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="select" label="Discounts" description="Please select any that apply:" name="discounts" multiple="multiple" className="form-control">&#13;
			<option label="Military" value="military">Military</option>&#13;
			<option label="55+" value="55">55+</option>&#13;
			<option label="Florida" value="florida">Florida</option>&#13;
			<option label="Healthcare" value="healthcare">Healthcare</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Will you use a valid passport or state issued birth certificate for travel?" description="Please select one" name="will-you-use-a-valid-passport-or-state-issued-birth-certificate-for-travel">&#13;
			<option label="Valid Passport" value="valid-passport">Valid Passport</option>&#13;
			<option label="Official State-Issued Birth Certificate" value="official-stateissued-birth-certificate">Official State-Issued Birth Certificate</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Additional Travelers"/>&#13;
		<field type="text" label="Additional Travelers Information" description="Please list additional travelers and their birthdates for quote" name="additional-travelers-information" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Travel Preferences"/>&#13;
		<field type="radio-group" required="true" label="Cabin Type" name="cabin-type" other="true">&#13;
			<option label="OT1 Ocean Terrace Suite" value="ot1-ocean-terrace-suite">OT1 Ocean Terrace Suite</option>&#13;
			<option label="OT2 Ocean Terrace Suite (same but prime location)" value="ot2-ocean-terrace-suite-same-but-prime-location">OT2 Ocean Terrace Suite (same but prime location)</option>&#13;
			<option label="Explora Journeys Ocean Grand Terrace Suite" value="explora-journeys-ocean-grand-terrace-suite">Explora Journeys Ocean Grand Terrace Suite</option>&#13;
			<option label="Explora Journeys Ocean Residence" value="explora-journeys-ocean-residence">Explora Journeys Ocean Residence</option>&#13;
		</field>&#13;
		<field type="radio-group" label="Bed preference" name="bed-preference">&#13;
			<option label="King" value="king">King</option>&#13;
			<option label="2 Double/Queen" value="2-double-queen">2 Double/Queen</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Additional Information"/>&#13;
		<field type="checkbox-group" required="true" label="Cruise Lines Previously Sailed" description="Please select cruises lines you have sailed" name="cruise-lines-previously-sailed" other="true">&#13;
			<option label="MSC " value="msc-">MSC </option>&#13;
			<option label="Explora Journeys" value="explora-journeys">Explora Journeys</option>&#13;
			<option label="Viking" value="viking">Viking</option>&#13;
			<option label="Silver Sea" value="silver-sea">Silver Sea</option>&#13;
			<option label="Regent" value="regent">Regent</option>&#13;
			<option label="Seabourn" value="seabourn">Seabourn</option>&#13;
			<option label="Ritz Carlton" value="ritz-carlton">Ritz Carlton</option>&#13;
			<option label="Oceania" value="oceania">Oceania</option>&#13;
			<option label="None" value="none">None</option>&#13;
		</field>&#13;
		<field type="radio-group" label="Email List Signup" description="Would you like to receive information on deals  promotions  solo and group bookings  etc.?" name="email-list-signup">&#13;
			<option label="Yes, please notify me of group cruises, deals, promos, etc." value="yes-please-notify-me-of-group-cruises-deals-promos-etc">Yes, please notify me of group cruises, deals, promos, etc.</option>&#13;
			<option label="Not at this time" value="not-at-this-time">Not at this time</option>&#13;
		</field>&#13;
		<field type="text" label="Notes" description="Please include any additional information you would like to share" name="notes" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>