<form-template>
	<fields><field type="text" subtype="text" required="true" label="First name" className="form-control" name="first-name"></field>
		<field type="text" required="true" label="First name&amp;nbsp;" name="prefix" subtype="text" className="form-control"/>
		<field type="text" label="Middle name" name="middle-name" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/>
		<field type="header" subtype="h2" label="Address"/>
		<field type="text" required="true" label="Line 1" name="address-line-1" subtype="text" className="form-control"/>
		<field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/>
		<field type="text" required="true" label="City" name="address-city" subtype="text" className="form-control"/>
		<field type="text" required="true" label="State" name="address-state" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Zip" name="address-zip" subtype="text" className="form-control"/>
		<field type="date" required="true" label="Date Of Birth" name="date-of-birth" className="form-control"/>
		<field type="radio-group" required="true" label="Gender&amp;nbsp;" name="gender-">
			<option label="Female " value="female-">Female </option>
			<option label="Male " value="male-">Male </option>
		</field>
		<field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>
		<field type="date" required="true" label="Check In Date&amp;nbsp;" name="starting-at" className="form-control"/>
		<field type="date" required="true" label="Check Out Date" name="ending-at" className="form-control"/>
		<field type="radio-group" required="true" label="Do you want a quote for travel insurance&amp;nbsp;" name="do-you-want-a-quote-for-travel-insurance-">
			<option label="Yes" value="yes">Yes</option>
			<option label="No" value="no">No</option>
		</field>
		<field type="textarea" label="Emergency Contact Information&amp;nbsp;" name="notes" subtype="textarea" className="form-control"/>
		<field type="textarea" label="Special Request&amp;nbsp;" description="Food Allergies  Floor Preference" name="special-request-" subtype="textarea" className="form-control"/>
	</fields>
</form-template>

Enter the amount you would like to authorize:

Please add or choose card to authorize:

Sign and agree to the terms and conditions:

By signing below, I authorize Limitless Travel/ and our vendor Limitless Travel use to charge the credit card provided herein. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated on this invoice.

Click to sign