Share your information with Ethan Myers

Ethan Myers

InteleTravel

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		<field type="header" subtype="h2" label="𝑪𝑪 𝑨𝒖𝒕𝒉𝒐𝒓𝒊𝒛𝒂𝒕𝒊𝒐𝒏 𝑭𝒐𝒓𝒎"/>&#13;
		<field type="textarea" required="true" label="TRAVEL PURCHASE AUTHORIZATION For Non-Website Purchases. Thank you for your purchase.&amp;nbsp;" placeholder="For Non-Website (Inteletravel.com) Purchases: InteleTravel.com &amp;amp; Luxe Xscapes LLC is pleased to confirm the following travel arrangements. To complete your transaction and confirm your arrangements  your signature on this authorization is required. This form is NOT required for electronic purchases you complete yourself on our website  www.InteleTravel.com  luxexscapes.inteletravel.com or its affiliates. Charges are payable ONLY to InteleTravel.com or the hotel  resort  tour operator  cruise line or other travel supplier.   If you have any questions  please be sure to reach out to Luxe Xscapes LLC." name="travel-purchase-authorization" value="InteleTravel.com &amp;amp; Travel with Coach Ethan  is pleased to confirm the following travel arrangements. To complete your transaction and confirm your arrangements your signature on this authorization is required. This form is NOT required for electronic purchases you complete yourself on our website  www.InteleTravel.com  or its affiliates. Charges are payable ONLY to InteleTravel.com &amp;amp;  Travel with Coach Ethan or the hotel, resort, tour operator, cruise line or other travel supplier. Independent Travel Advisors may not accept and process charges through any other account, or accept checks, cash or other forms of payment." className="form-control"/>&#13;
		<field type="header" subtype="h1" label="TRAVEL INSURANCE WAIVER&amp;nbsp;"/>&#13;
		<field type="paragraph" subtype="p" label="For your protection, Travel Insurance is strongly recommended and available upon request from InteleTravel.com. You can enroll online for travel protection for Medical Expenses, Baggage Delays/Loss, Trip Delay or Cancellation, and other coverage, or your InteleTravel.com Independent Travel Advisor can arrange coverage for you. For an online insurance quote and purchase, go to www.InteleTravel.com and click on Insure It. To decline recommended travel insurance, your signature on this insurance waiver form is required. Final Travel Documents (tickets, vouchers, etc.) cannot be sent to you prior to receipt of the signed insurance waiver. Travel Documents (tickets, vouchers, etc.) cannot be sent to you prior to receipt of the signed insurance waiver. "/>&#13;
		<field type="radio-group" required="true" label="I authorize Inteletravel.com, this supplier and/or Travel with Coach Ethan to charge for the authorized amount below." inline="true" name="i-authorize-inteletravelcom-this-supplier-andor-luxe-xscapes-llc-to-charge-for-the-authorized-amount-below">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
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		<field type="header" subtype="h1" label="𝑵𝒂𝒎𝒆 𝒐𝒏 𝑪𝒂𝒓𝒅&amp;nbsp;"/>&#13;
		<field type="text" required="true" label="First Name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Middle Initial" 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="header" subtype="h1" label="𝑩𝒊𝒍𝒍𝒊𝒏𝒈 𝑨𝒅𝒅𝒓𝒆𝒔𝒔"/>&#13;
		<field type="text" required="true" label="Address Line 1" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Address 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="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="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;
		<field type="header" subtype="h1" label="Important Dates"/>&#13;
		<field type="date" label="Birthday" name="date-1774219445868" className="form-control"/>&#13;
		<field type="date" label="Anniversary&amp;nbsp;" name="anniversary-" className="form-control"/>&#13;
		<field type="textarea" required="true" label="𝑨𝒅𝒅𝒊𝒕𝒊𝒐𝒏𝒂𝒍 𝑻𝒓𝒂𝒗𝒆𝒍𝒆𝒓&#39;𝒔 𝑵𝒂𝒎𝒆𝒔 (𝑨𝒔 𝑬𝒏𝒕𝒆𝒓𝒆𝒅 𝒐𝒏 𝑷𝒂𝒔𝒔𝒑𝒐𝒓𝒕) &amp;amp; 𝑫𝑶𝑩 + 𝑹𝒐𝒐𝒎𝒊𝒏𝒈 𝑨𝒔𝒔𝒊𝒈𝒏𝒎𝒆𝒏𝒕&amp;nbsp;" placeholder="Please include all rooming arrangements." name="------------" rows="3" className="form-control"/>&#13;
	</fields>&#13;
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