Share your information with Misty Daugherty

Misty Daugherty

Allstop Travel

<html>
  <body>
<form-template>
  <fields>
    <field type="header" subtype="h2" label="Contact Information"/>
    <field type="text" subtype="text" required="true" label="First name" name="first-name" className="form-control"/>
    <field type="text" subtype="text" label="Middle name" name="middle-name" className="form-control"/>
    <field type="text" subtype="text" required="true" label="Last name" name="last-name" className="form-control"/>
    <field type="text" subtype="text" label="Preferred name (nickname)" name="preferred-name" className="form-control"/>
    <field type="text" subtype="text" required="true" label="Primary email address" name="email" className="form-control"/>
    <field type="text" subtype="text" label="Primary phone number" name="phone-number" className="form-control"/>
    <field type="header" subtype="h2" label="Passport Information"/>
    <field type="text" subtype="text" label="Full name as it appears on passport" name="passport-name" className="form-control"/>
    <field type="text" subtype="text" label="Passport number" name="passport-number" className="form-control"/>
    <field type="text" subtype="text" label="Country of issue" name="passport-country-of-issue" className="form-control"/>
    <field type="date" label="Date of birth" name="birthday" className="form-control"/>
    <field type="date" label="Date of issue" name="passport-date-of-issue" className="form-control"/>
    <field type="date" label="Date of expiration" name="passport-date-of-expiration" className="form-control"/>
    <field type="radio-group" label="Sex" name="gender">
      <option value="female" label="F">F</option>
      <option value="male" label="M">M</option>
      <option value="other" label="X">X</option>
    </field>
    <field type="header" subtype="h2" label="Emergency Contact Information"/>
    <field type="text" subtype="text" label="Full name" name="emergency-contact-full-name" className="form-control"/>
    <field type="text" subtype="text" label="Phone number" name="emergency-contact-phone-number" className="form-control"/>
    <field type="text" subtype="text" label="Relationship to you" name="emergency-contact-relationship" className="form-control"/>
  </fields>
</form-template>
</body>
</html>