Share your information with Jeanine Cioffi

Jeanine Cioffi

Lavishly Travel

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h1" label="Cruises Only Request"/>&#13;
		<field type="header" subtype="h2" label="Full name"/>&#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="text" label="Preferred name" name="preferred-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="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="date" required="true" label="What is the approximate start date for this trip?" name="what-is-the-approximate-start-date-for-this-trip" className="form-control"/>&#13;
		<field type="date" required="true" label="What is the approximate end date for this trip?" name="what-is-the-approximate-end-date-for-this-trip" className="form-control"/>&#13;
		<field type="text" required="true" label="How many total travelers?" name="number-of-travelers" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Have you sailed on a cruise in the past and if yes, what cruiselines did you use and how was your experience?" name="have-you-sailed-on-a-cruise-in-the-past-and-if-yes-what-cruiselines-did-you-use-and-how-was-your-experience" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" required="true" label="What type of cruise are you interested?" name="what-type-of-cruise-are-you-interested">&#13;
			<option label="Luxury River Cruise" value="luxury-river-cruise">Luxury River Cruise</option>&#13;
			<option label="Luxury Ocean Cruise" value="luxury-ocean-cruise">Luxury Ocean Cruise</option>&#13;
			<option label="Moderate River Cruise" value="moderate-river-cruise">Moderate River Cruise</option>&#13;
			<option label="Moderate Ocean Cruise" value="moderate-ocean-cruise">Moderate Ocean Cruise</option>&#13;
			<option label="Budget Ocean Cruise" value="budget-ocean-cruise">Budget Ocean Cruise</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="What is your preferred destination?" name="what-is-your-preferred-destination">&#13;
			<option label="Alaska" value="alaska">Alaska</option>&#13;
			<option label="Caribbean" value="caribbean">Caribbean</option>&#13;
			<option label="Europe" value="europe">Europe</option>&#13;
			<option label="Hawaii" value="hawaii">Hawaii</option>&#13;
			<option label="Mexico" value="mexico">Mexico</option>&#13;
			<option label="USA ( New England)" value="usa-new-england">USA ( New England)</option>&#13;
			<option label="USA Mississippi River " value="usa-mississippi-river-">USA Mississippi River </option>&#13;
		</field>&#13;
		<field type="text" required="true" label="What Ports would you like to sail from/to?" name="what-ports-would-you-like-to-sail-fromto" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="What type of cabin would you like?&amp;nbsp;" name="what-type-of-cabin-would-you-like-">&#13;
			<option label="Suite" value="suite">Suite</option>&#13;
			<option label="Balcony with full view" value="balcony-with-full-view">Balcony with full view</option>&#13;
			<option label="Balcony with obstructed view" value="balcony-with-obstructed-view">Balcony with obstructed view</option>&#13;
			<option label="Oceanview no balcony" value="oceanview-no-balcony">Oceanview no balcony</option>&#13;
			<option label="Inside Cabin no view" value="inside-cabin-no-view">Inside Cabin no view</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="How many days would you like to be on this cruise?" name="how-many-days-would-you-like-to-be-on-this-cruise">&#13;
			<option label="3-4" value="34">3-4</option>&#13;
			<option label="5-7" value="57">5-7</option>&#13;
			<option label="7-10" value="710">7-10</option>&#13;
			<option label="10-14" value="1014">10-14</option>&#13;
			<option label="&gt;14" value="14">&gt;14</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Would you like cruiseline&amp;nbsp; trip protection?" name="would-you-like-cruiseline-trip-protection">&#13;
			<option label="yes" value="yes">yes</option>&#13;
			<option label="no" value="no">no</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="What is your overall budget PER PERSON including all taxes, fees, cruise fare and insurance. if you selected yes" name="what-is-your-overall-budget-per-person-including-all-taxes-fees-cruise-fare-and-insurance-if-you-selected-yes" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="How many cabins do you need?" name="how-many-cabins-do-you-need" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Please provide any other information that you would like us to know here including any cruise lines you would like us to check. Additionally, we will need to know any special needs, medical needs, celebrations, or if you are military.&amp;nbsp;" name="please-provide-any-other-information-that-you-would-like-us-to-know-here-" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="Will you need us to assist with air?" name="will-you-need-us-to-assist-with-air">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Would you like us to help book any pre or post cruise hotel?" name="would-you-like-us-to-help-book-any-pre-or-post-cruise-hotel">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="What days and times are you available for phone calls?" name="what-days-and-times-are-you-available-for-phone-calls" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="What time zone are you located" name="what-time-zone-are-you-located">&#13;
			<option label="Eastern" value="eastern">Eastern</option>&#13;
			<option label="Central" value="central">Central</option>&#13;
			<option label="Mountain" value="mountain">Mountain</option>&#13;
			<option label="Pacific" value="pacific">Pacific</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Thank You"/>&#13;
		<field type="paragraph" subtype="p" label="Thank you for filling out this form.&amp;nbsp; We will be in touch within 24 business hours.&amp;nbsp;"/>&#13;
		<field type="textarea" label="Other Notes for Me" name="other-notes-for-me" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>