<div class="row">
    <div class="col-md-6">
        <p>
            Name(s)
            [text onsinger-text-40 class:travelers_name placeholder "e.g. Max, David, Matt" ]
        </p>
    </div>
    <div class="col-md-6">
        <p>Surname(s)
            [text Surname-text-40 placeholder "e.g. Cutt, Gallardo, Cutt"]
        </p>
    </div>
    <div class="col-md-3">
        <p>
            * Number of Traveler(s)
            [number* no-Travelers min:1 max:99]
        </p>
    </div>
    <div class="col-md-9">
        <p> * Cell Phone Number
            [tel* cellphone-tel-509]<span class="smalltext">(If SeaFarer phone number is not available then input your phone number and deselect Apple Crew tracking at bottom of page)</span>
        </p>
    </div>
    <div class="col-md-6">
        <p>
            * Location Address
            [text* location-text-8491]
        </p>
    </div>
    <div class="col-md-6">
        <p>Flight Line Address
            [text Flight-text-5661]
        </p>
    </div>
    <div class="col-md-6">
        <p>
            * Date
            [date* date-256 id:reservation_date]
        </p>
    </div>
    <div class="col-md-6">
        <p class="input-group clockpicker" data-placement="bottom" data-align="top" data-autoclose="true"> * Time
            [text* journey-text-488 class:form-control]
        </p>
    </div>
    <div class="col-md-12">
        <h4> Flight Crews & Dredging Crews Shuttle Destination
        </h4>
    </div>
    <div class="col-md-6">
        <p>Hotel
            [text Hotel-text-8491]
        </p>
    </div>
    <div class="col-md-6">
        <p>ACTS Lounge
            [text Lounge-text-8492]
        </p>
    </div>
    <div class="col-md-6">
        <p> PickUp Date
            [date* PickUp-date-8734 id:reservation_date]
        </p>
    </div>
    <div class="col-md-6">
        <p class=" clockpicker" data-placement="bottom" data-align="top" data-autoclose="true">PickUp Time 
            [text* PickUpTime-text-8788 class:form-control ]
        </p>
    </div>
    <div class="col-md-4 ">
        <p>Ship Name
            [text ship-name id:select2_ship_name]
        </p>
    </div>
    <div class="col-md-4">
        <p>Ship #
            [text ship-number id:ship_no_val]
        </p>
    </div>
    <div class="col-md-4">
        <p>* Ship Location
            [select* ship-location class:ship_location]
        </p>
    </div>
    <div class="col-md-6">
        <p>* Date
            [date* destination-date id:reservation_date]
        </p>
    </div>
    <div class="col-md-6">
        <p class=" clockpicker" data-placement="bottom" data-align="top" data-autoclose="true"> * Time
            [text* destination-time class:form-control]
        </p>
    </div>
    <div class="col-md-6">
        <p>Flight Line Address
            [text Flight-text-5501]
        </p>
    </div>
    <div class="col-md-6">
        <p>Special Instructions
            [text Instructions-text-550]
        </p>
    </div>
    <div class="col-md-12">
        <p>* I want Agent Updates and Tracking during times of Travel, and I have informed the traveler to accept the Agent Crew Tracking text during travel?
            [radio sradio-9797 default:1 "Yes" "No"]
        </p>
    </div>
    <div class="col-md-3" style="text-align: center;">
        <p>CBP Service
            [radio radio-485 default:2 "Yes" "No"]
        </p>
    </div>
    <div class="col-md-3" style="text-align: center;">
        <p>Gate & TWIC Service
            [radio radio-4855 default:2 "Yes" "No"]
        </p>
    </div>
    <div class="col-md-3" style="text-align: center;">
        <p>Boarding Pass Service
            [radio radio-48555 default:2 "Yes" "No"]
        </p>
    </div>
    <div class="col-md-3" style="text-align: center;">
        <p>Airport Assist & Crew Wait Service
            [radio radio-485555 default:2 "Yes" "No"]
        </p>
    </div>

    <div class="col-md-4">
        <div class="single-contact-field">
            [hidden total_price class:total_price ]
            [submit id:submit class:gauto-theme-btn "Submit"]
        </div>
    </div>
    <div class="col-md-12">
        <p><span class="smalltext">* The proprietary tracking software used on this site is experimental and still underdevelopment; therefore the company nor any of its affiliates, can make any guarantees regarding it’s reliability or accuracy at this time.</span></p>
    </div>
</div>