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Roxana L.

Roxy Global Travel / TravelFun.Biz, LLC

<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" 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" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" label="Do you have a valid passport? (Required for international travel)" name="do-you-have-a-valid-passport-required-for-international-travel">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>