<div class="row">
    <div class="col-md-12">
        <h4>Special Shuttle Pick Up
        </h4>
    </div>
    <div class="col-md-4">
        <p>
            * Number of Traveler(s)
            [number* no-Travelers min:1 max:99]
        </p>
    </div>
    <div class="col-md-4">
    	<p>
            Name(s)
            [text onsinger-text-40 class:travelers_name placeholder "e.g. Max, David, Matt" ]
        </p>
    </div>
    <div class="col-md-4">
        <p>Surname(s)
            [text Surname-text-40 placeholder "e.g. Cutt, Gallardo, Cutt"]
        </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-4">
        <p>
            * Hotel
            [text* hotel-text-8491]
        </p>
    </div>
    <div class="col-md-4">
        <p>
            * Date
            [date* date-256 id:reservation_date]
        </p>
    </div>
    <div class="col-md-4">
        <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">
        <p> Cell Phone
            [tel cellphone-tel-509]
        </p>
    </div>
    <div class="col-md-12">
        <h4> Destination:
        </h4>
    </div>
    <div class="col-md-4">
        <p>Shopping address
            [text address-text-550]
        </p>
    </div>
    <div class="col-md-4">
        <p>Doctors Visit address
            [text Visit-text-5501]
        </p>
    </div>
    <div class="col-md-4">
        <p>Pharmacy address
            [text paddress-text-550]
        </p>
    </div>
    <div class="col-md-4">
        <p>Restaurant address
            [text Restaurant-text-550]
        </p>
    </div>
    <div class="col-md-4">
        <p>Other address
            [text Other-text-5501]
        </p>
    </div>
    <div class="col-md-4">
        <p>Conference address
            [text Conference-text-550]
        </p>
    </div>
    <div class="col-md-12">
        <p>Special Instructions
            [text Special-text-550]
        </p>
    </div>
    <div class="col-md-12">
        <p>Also we provide CC services, with invoiced reimbursements.
            I will need Charge Card Srervices for this run.
            [radio radio-662 default:1 "Yes" "No"]
        </p>
    </div>
    <div class="col-md-12">
        <h4>Return Special Shuttle Pick Up & Destination
        </h4>
    </div>
    <div class="col-md-6">
        <p class=" clockpicker" data-placement="bottom" data-align="top" data-autoclose="true">* Time
            [text* return-journey-text-488 class:form-control]
        </p>
    </div>
    <div class="col-md-6">
        <p>
            * Date
            [date* return-date-256 id:reservation_date]
        </p>
    </div>
    <div class="col-md-6">
        <p> Pick up Address
            [text Pick-text-550]
        </p>
    </div>
    <div class="col-md-6">
        <p> Destination
            [text Destination-text-550]
        </p>
    </div>
    <div class="col-md-12">
        <p>Special Instructions
            [text Return-Destination-text-551]
        </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>