<div class="row">
    <div class="col-md-12">
        <h4>Courier Shuttle Pick Up
        </h4>
    </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-6">
        <p>* No. of pkgs
            [number* pkgs-no min:1 class:pkgs-no ]
        </p>
    </div>
    <div class="col-md-6">
        <p>* Weight (in lbs)
            [text* Weight-text-5501]
        </p>
    </div>
    <div class="col-md-12">
        <p>* Destination
            [textarea* Destination-textarea-950]
        </p>
    </div>
<div class="col-md-4" style="text-align: center;">
        <p>CBP Service
            [radio radio-485 default:2 "Yes" "No"]
        </p>
    </div>
    <div class="col-md-4" style="text-align: center;">
        <p>Gate & TWIC Service
            [radio radio-4855 default:2 "Yes" "No"]
        </p>
    </div>
    <div class="col-md-4" style="text-align: center;">
        <p>Boarding Pass Service
            [radio radio-48555 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">* If the destination is a ship, there will be an extra fee, if we have to board the vessel.</span>
        </p>
    </div>
</div>