<html> <body> <form-template> <fields> <field type="header" subtype="h1" label="Refund Request"/> <field type="date" required="true" label="Date of request" name="date-1659634998377" className="form-control"/> <field type="header" subtype="h2" label="Full name"/> <field type="text" label="Prefix" name="prefix" subtype="text" className="form-control"/> <field type="text" required="true" label="First name" name="first-name" 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="text" label="Suffix" name="suffix" subtype="text" className="form-control"/> <field type="text" label="Preferred name" name="preferred-name" subtype="text" className="form-control"/> <field type="text" required="true" label="Original destination" name="original-destination" subtype="text" className="form-control"/> <field type="date" label="Scheduled Date of Departure" name="scheduled-date-of-departure" className="form-control"/> <field type="radio-group" required="true" label="Which do you prefer?" name="which-do-you-prefer"> <option label="Refund to Card used" value="refund-to-card-used">Refund to Card used</option> <option label="Refund by check (see terms and conditions)" value="refund-by-check-see-terms-and-conditions">Refund by check (see terms and conditions)</option> </field> <field type="header" subtype="h1" label="If you are requesting a check by mail, lease enter the name that should be on the check and the address to where you wish it to be sent.&nbsp;"/> <field type="header" subtype="h2" label="Address"/> <field type="text" 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" label="City" name="address-city" subtype="text" className="form-control"/> <field type="text" label="State" name="address-state" subtype="text" className="form-control"/> <field type="text" label="Zip" name="address-zip" subtype="text" className="form-control"/> <field type="text" label="Country" name="address-country" subtype="text" className="form-control"/> <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"/> </fields> </form-template> </body> </html>
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