Share your information with Miki Holder

Miki Holder

I Travel with Miki

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Full name"/>&#13;
		<field type="text" required="true" label="First name" name="first-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="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="header" subtype="h2" label="Where are you from?"/>&#13;
		<field type="text" required="true" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Zip" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="What Trip are you Interested in?"/>&#13;
		<field type="select" required="true" label="Trip Options" name="trip-options" className="form-control">&#13;
			<option label="Spain &amp; Portugal in Depth" value="spain-portugal-in-depth">Spain &amp; Portugal in Depth</option>&#13;
			<option label="Italy" value="italy">Italy</option>&#13;
			<option label="Both" value="both">Both</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="Roommate"/>&#13;
		<field type="text" label="Roommates Name" name="roommates-name" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>