<div class="row">
<div class="col-md-12">
<h4>LET'S GET STARTED</h4>
</div>
<div class="col-md-6">
<p>
Your Name (Agent or Travel Coordinator) 
    [text text-8491]
</p>
</div>
<div class="col-md-6">
<p>
    Email
[email* email-184 ]
</p>
</div>
<div class="col-md-12">
<p>
Phone
    [tel* tel-817]
</p>
</div>

<div class="col-md-12">
<p>
Responsible Billing Party Name
[text name-text-316] 
</p>
</div>
<div class="col-md-6">
<p>
Email
    [email* billing-email-184 ]
</p>
</div>
<div class="col-md-6">
<p>Phone
[tel phone-tel-509 ]
</p>
</div>
<div class="col-md-12">
<p>
Address
[textarea address-textarea-897]    
</p>
</div>

<div class="col-md-12">
<p>
To Schedule Shuttle Services, Choose Your Traveler Category. 
[select menu-104 "Mariner" "Flight Crew & Dredging Crew" " Special Shuttles" "Courier Shuttle"] 
</p>
</div>
<div class="col-md-12">
<p> Select
[select menu-784 "ON-SIGNER" "OFF- SIGNER"]
</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>