Name:	*	[text* Name]
Email:	*	[email* email]
Country of Origin:	*	[select* Country "" "Afghanistan" "Åland Islands" "Albania" "Algeria" "American Samoa" "Andorra" "Angola" "Anguilla" "Antarctica" "Antigua and Barbuda" "Argentina" "Armenia" "Aruba" "Australia" "Austria" "Azerbaijan" "Bahamas" "Bahrain" "Bangladesh" "Barbados" "Belarus" "Belgium" "Belize" "Benin" "Bermuda" "Bhutan" "Bolivia" "Bosnia and Herzegovina" "Botswana" "Bouvet Island" "Brazil" "British Indian Ocean territory" "Brunei Darussalam" "Bulgaria" "Burkina Faso" "Burundi" "Cambodia" "Cameroon" "Canada" "Cape Verde" "Cayman Islands" "Central African Republic" "Chad" "Chile" "China" "Christmas Island" "Cocos (Keeling) Islands" "Colombia" "Comoros" "Congo" "Congo, Democratic Republic" "Cook Islands" "Costa Rica" "Côte d'Ivoire (Ivory Coast)" "Croatia (Hrvatska)" "Cuba" "Cyprus" "Czech Republic" "Denmark" "Djibouti" "Dominica" "Dominican Republic" "East Timor" "Ecuador" "Egypt" "El Salvador" "Equatorial Guinea" "Eritrea" "Estonia" "Ethiopia" "Falkland Islands" "Faroe Islands" "Fiji" "Finland" "France" "French Guiana" "French Polynesia" "French Southern Territories" "Gabon" "Gambia" "Georgia" "Germany" "Ghana" "Gibraltar" "Greece" "Greenland" "Grenada" "Guadeloupe" "Guam" "Guatemala" "Guinea" "Guinea-Bissau" "Guyana" "Haiti" "Heard and McDonald Islands" "Honduras" "Hong Kong" "Hungary" "Iceland" "India" "Indonesia" "Iran" "Iraq" "Ireland" "Israel" "Italy" "Jamaica" "Japan" "Jordan" "Kazakhstan" "Kenya" "Kiribati" "Korea (north)" "Korea (south)" "Kuwait" "Kyrgyzstan" "Lao People's Democratic Republic" "Latvia" "Lebanon" "Lesotho" "Liberia" "Libyan Arab Jamahiriya" "Liechtenstein" "Lithuania" "Luxembourg" "Macao" "Macedonia, Former Yugoslav Republic Of" "Madagascar" "Malawi" "Malaysia" "Maldives" "Mali" "Malta" "Marshall Islands" "Martinique" "Mauritania" "Mauritius" "Mayotte" "Mexico" "Micronesia" "Moldova" "Monaco" "Mongolia" "Montenegro" "Montserrat" "Morocco" "Mozambique" "Myanmar" "Namibia" "Nauru" "Nepal" "Netherlands" "Netherlands Antilles" "New Caledonia" "New Zealand" "Nicaragua" "Niger" "Nigeria" "Niue" "Norfolk Island" "Northern Mariana Islands" "Norway" "Oman" "Pakistan" "Palau" "Palestinian Territories" "Panama" "Papua New Guinea" "Paraguay" "Peru" "Philippines" "Pitcairn" "Poland" "Portugal" "Puerto Rico" "Qatar" "Réunion" "Romania" "Russian Federation" "Rwanda" "Saint Helena" "Saint Kitts and Nevis" "Saint Lucia" "Saint Pierre and Miquelon" "Saint Vincent and the Grenadines" "Samoa" "San Marino" "Sao Tome and Principe" "Saudi Arabia" "Senegal" "Serbia" "Seychelles" "Sierra Leone" "Singapore" "Slovakia" "Slovenia" "Solomon Islands" "Somalia" "South Africa" "South Georgia and the South Sandwich Islands" "Spain" "Sri Lanka" "Sudan" "Suriname" "Svalbard and Jan Mayen Islands" "Swaziland" "Sweden" "Switzerland" "Syria" "Taiwan" "Tajikistan" "Tanzania" "Thailand" "Togo" "Tokelau" "Tonga" "Trinidad and Tobago" "Tunisia" "Turkey" "Turkmenistan" "Turks and Caicos Islands" "Tuvalu" "Uganda" "Ukraine" "United Arab Emirates" "United Kingdom" "United States of America" "Uruguay" "Uzbekistan" "Vanuatu" "Vatican City" "Venezuela" "Vietnam" "Virgin Islands (British)" "Virgin Islands (US)" "Wallis and Futuna Islands" "Western Sahara" "Yemen" "Zaire" "Zambia" "Zimbabwe"]
Date of Arrival:	*	[select* Day "1" "2" "3" "4" "5" "6" "7" "8" "9" "10" "11" "12" "13" "14" "15" "16" "17" "18" "19" "20" "21" "22" "23" "24" "25" "26" "27" "28" "29" "30" "31"] - [select* Month "January" "February" "March" "April" "May" "June" "July" "August" "September" "October" "November" "December"] - [select* Year "2011" "2012" "2013" "2014"]
Number of Nights:	*	[select* Nights "1" "2" "3" "4" "5" "6" "7" "8" "9" "10" "11" "12" "13" "14" "15" "16" "17" "18" "19" "20" "21" "22" "23" "24" "25" "26" "27" "28" "29" "30"]
Preferred Bungalow:		[checkbox RumahManis use_label_element "Rumah Manis"] [checkbox Orchid use_label_element "Orchid"] [checkbox JungleHouse use_label_element "Jungle House"] [checkbox TreeHouse use_label_element "Tree House"]
Airline:		[text Airline]
Flight Number:		[text FlightNumber]
Transfer required:	*	[select* TransferRequired "Yes" "No"]
Number of Guests:		[select Adults "1" "2" "3" "4" "5" "6" "7" "8" "9" "10"] Adults - [select Children "0" "1" "2" "3" "4" "5" "6" "7" "8" "9" "10"] Children
Age of Children:		[text AgeOfChildren]
Interested in:		[checkbox Activity1 use_label_element "Edible Garden Tour"] [checkbox Activity2 use_label_element "Walking"] [checkbox Activity3 use_label_element "Mountain Biking"] [checkbox Activity4 use_label_element "Trekking"] [checkbox Activity5 use_label_element "Massage"] [checkbox Activity6 use_label_element "Workshop"] [checkbox Activity7 use_label_element "Orangutan and elephant trekking, Sumatra"]
Comments :		[textarea Comments]
Input code shown :	*	[captchac captcha-799 size:m] [captchar captcha-799]
		* required fields
		[submit "Send"]