<form-template>
	<fields>
		<field type="header" subtype="h1" label="What Is Uplift?"/>
		<field type="paragraph" subtype="p" label="Uplift is a company that allows you to finance your vacation balance. Uplift pays your vacation balance in full, and gives you 12 months to pay them back. The loans are credit based. Your credit score is only impacted when you accept the loan, not when you check your rate. You are required to pay a small deposit (equal to your monthly payment amount) when you accept an uplift financing agreement.&amp;nbsp;"/>
		<field type="header" subtype="h3" label="To &amp;nbsp;get started with Uplift, Complete the information below. Your Travel Agent will then follow up requesting more information or sending you a link to complete the application."/>
		<field type="header" subtype="h2" label="Full name"/>
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/>
		<field type="date" required="true" label="Birthday" name="birthday" className="form-control"/>
		<field type="header" subtype="h2" label="Contact Information"/>
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Cell Phone number" name="phone-number" subtype="text" className="form-control"/>
		<field type="text" required="true" label="Address : Line 1" name="address-line-1" subtype="text" className="form-control"/>
		<field type="text" label="Address 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="radio-group" required="true" label="How Would You Like To Receive Your Uplift Application" name="how-would-you-like-to-receive-your-uplift-application">
			<option label="Send Via Email" value="send-via-email">Send Via Email</option>
			<option label="Send Via Text" value="send-via-text">Send Via Text</option>
		</field>
		<field type="paragraph" subtype="p" label="***Emails &amp;nbsp;requests will come from the Uplift Support email address. Text requests will come from an toll free &amp;nbsp;area code such as (833). The links in these emails or text messages are only valid for 24 hours.***"/>
		<field type="radio-group" required="true" label="I would like to use Uplift to:" name="i-would-like-to-use-uplift-to">
			<option label="Pay For An Existing Trip " value="pay-for-an-existing-trip-">Pay For An Existing Trip </option>
			<option label="Pay For A New Trip" value="pay-for-a-new-trip">Pay For A New Trip</option>
		</field>
		<field type="text" label="Comments" description="Please list any additional instructions or comments for the agent here such as notes, booking number, requests, etc." name="comments" subtype="text" className="form-control"/>
		<field type="paragraph" subtype="p" label="The travel agent will review your information and advise of the next steps.&amp;nbsp;If this request is for an existing trip your current balance will be used.&amp;nbsp;If this is for a new trip, your selected itinerary balance will be used.The uplift link only lasts for 24 hours, please submit this form when you are ready to complete the financing application. &amp;nbsp;"/>
		<field type="header" subtype="h3" label="POLICIES &amp;amp; RELESE OF LIABILITY"/>
		<field type="checkbox-group" required="true" label="CANCELLATION POLICY &amp;amp; RELEASE OF LIABILITY" name="cancellation-policy-release-of-liability">
			<option label="Yes I have read, accept, and agree to abide by Prissi Travels &amp; The Travel Suppliers Refund and Cancellation Policy. I understand that deposits and some payments are nonrefundable as stated in the terms and conditions, and that cancellation and penalty fees may apply." value="yes-i-have-read-accept-and-agree-to-abide-by-prissi-travels-the-travel-suppliers-refund-and-cancellation-policy-i-understand-that-deposits-and-some-payments-are-nonrefundable-as-stated-in-the-terms-and-conditions-and-that-cancellation-and-penalty-fees-may-apply">Yes I have read, accept, and agree to abide by Prissi Travels &amp; The Travel Suppliers Refund and Cancellation Policy. I understand that deposits and some payments are nonrefundable as stated in the terms and conditions, and that cancellation and penalty fees may apply.</option>
		</field>
		<field type="checkbox-group" required="true" label="RELEASE OF LIABILITY" name="release-of-liability">
			<option label="Yes, I understand that Prissi Travels is not responsible for any injury, loss, or damage to person or property, death, delay or inconvenience in connection with this trip or any other cause beyond the direct control of Prissi Travels" value="yes-i-understand-that-prissi-travels-is-not-responsible-for-any-injury-loss-or-damage-to-person-or-property-death-delay-or-inconvenience-in-connection-with-this-trip-or-any-other-cause-beyond-the-direct-control-of-prissi-travels">Yes, I understand that Prissi Travels is not responsible for any injury, loss, or damage to person or property, death, delay or inconvenience in connection with this trip or any other cause beyond the direct control of Prissi Travels</option>
		</field>
	</fields>
</form-template>