JEK TRAVELS

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	<fields>&#13;
		<field type="header" subtype="h1" label="BUY NOW, PAY LATER WITH UPLIFT"/>&#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" 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" required="true" label="Choose Trip Type" inline="true" name="choose-trip-type">&#13;
			<option label="Hosted Group Trip" value="hosted-group-trip">Hosted Group Trip</option>&#13;
			<option label="Private Trip" value="private-trip">Private Trip</option>&#13;
		</field>&#13;
		<field type="text" required="true" label="Amount You Want To Finance" placeholder="$2500" name="amount-you-want-to-finance" subtype="text" className="form-control"/>&#13;
		<field type="paragraph" subtype="p" label="Please Note: If you are requesting funds for yourself and you have a roommate, your roommate must have their deposit ready at same time in order for our agency to secure your room. If you like you can use part of your approved funds to pay the deposit for your roommate. Your roommate will need to apply as well &amp;nbsp;or we can book the single occupancy room package and your roommate can be added at a later date. (All options will be discussed before any payment is applied)"/>&#13;
		<field type="paragraph" subtype="p" label="Travel insurance is &amp;nbsp;HIGHLY RECOMMENDED to secure your investment with JEK Travels. All travel packages are non-refundable and non- transferrable. A travel quote can be sent to you from our travel insurance partners via email."/>&#13;
	</fields>&#13;
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