<div class="row">

<div class="col-md-12">
<h4>On Signer Traveler, Origin Information:</h4>
<p>
Name (s) and number of Traveler(s): 
[text onsinger-text-40]
</p>
</div>
<div class="col-md-6">
<p>Surname(s)
[text Surname-text-40]
</p>
</div>
<div class="col-md-6">
<p>Cell Phone #
[tel* cell-tel-264]
</p>
</div>

<div class="col-md-6">
<p>Departure Country 
[text country-text-40]
</p>
</div>
<div class="col-md-6">
<p>Departure City
[text city-text-40]
</p>
</div>
<div class="col-md-6">
<p>Airlines
[text Airlines-text-40]
</p>
</div>
<div class="col-md-6">
<p>Flight #
[text Flight-text-40]
</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-4855 default:2 "Yes" "No"]
</p>
</div>

<div class="col-md-12">
<h4>ON SIGNER SHUTTLE PICK-UP & Arrival Information
</h4>
</div>

<div class="col-md-6">
<p>*Date
[date* date-983 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>*Airlines Name:
[text Airlines-text-41]
</p>
</div>
<div class="col-md-6">
<p>* Flight #
[text Flight-text-41]
</p>
</div>

<div class="col-md-12">
<h4>ON SIGNER SHUTTLE DESTINATION INFORMATION
</h4>
</div>
<div class="col-md-6">
<p>* Ship Name:
[text ship-text-40]
</p>
</div>
<div class="col-md-6">
<p>*Ship ETA Date
[date* date-9834 id:reservation_date]
</p>
</div>
<div class="col-md-12">
<p class="input-group clockpicker" data-placement="bottom" data-align="top" data-autoclose="true">Time
    [text* journey-text-4888 class:form-control ]
 </p>
</div>
<div class="col-md-4">
<p>Ship
[text Ship-text-190]
</p>
</div>
<div class="col-md-4">
<p>HOTEL
[text HOTEL-text-190]
</p>
</div>
<div class="col-md-4">
<p>ACTS Lounge
[text Lounge-text-190]
</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-4">
<div class="single-contact-field">
      [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>