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	<description>Your Catholic Tour Company</description>
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		<title>Fr. Ugo, Charles C.  &#8211; St. Joseph Parish, Renovo, PA &#8211; HL-IR (2012, September 3-16)</title>
		<link>http://www.proximotravel.com/priest-trip/fr-ugo-charles-c-st-joseph-parish-renovo-pa-hl-ir-2012-september-3-16/</link>
		<comments>http://www.proximotravel.com/priest-trip/fr-ugo-charles-c-st-joseph-parish-renovo-pa-hl-ir-2012-september-3-16/#comments</comments>
		<pubDate>Wed, 22 Feb 2012 02:47:00 +0000</pubDate>
		<dc:creator>Carrie Etzel</dc:creator>
				<category><![CDATA[Holy Land and Italy Regular - Priest Trips]]></category>
		<category><![CDATA[Priest Trips]]></category>

		<guid isPermaLink="false">http://www.proximotravel.com/?p=8001</guid>
		<description><![CDATA[Jerusalem • Bethlehem • Galilee • Capernaum • Rome • Tuscany • Florence • Assisi • Venice Fr. Charles C. Ugo, Pastor St. Joseph, Renovo, PA Dates 2012 September 03 &#8211; 16 14 Days $4,699 Airfare Included]]></description>
			<content:encoded><![CDATA[<h3 style="text-align: center;">Jerusalem • Bethlehem • Galilee • Capernaum • Rome • Tuscany • Florence • Assisi • Venice</h3>
<hr />
<h2>Fr. Charles C. Ugo, Pastor<br />
St. Joseph, Renovo, PA</h2>
<h3>Dates 2012</h3>
<ul>
<li>September 03 &#8211; 16</li>
<li>14 Days $4,699</li>
<li>Airfare Included</li>
</ul>

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                            <h3 class='gform_title'>Holy Land and Italy Regular (2012, Sept. 03-16) - Trip Registration</h3>
                            <span class='gform_description'>Please fill out the form below with your details to reserve your trip now.</span>
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                            <ul id='gform_fields_850' class='gform_fields top_label'><li id='field_850_50' class='gfield     gform_hidden' ><input name='input_50' id='input_850_50' type='hidden' class='gform_hidden' value='Fr. Ugo, Charles C.  - St. Joseph Parish, Renovo, PA - HL-IR (2012, September 3-16)' /></li><li id='field_850_55' class='gfield     gform_hidden' ><input name='input_55' id='input_850_55' type='hidden' class='gform_hidden' value='02/22/2012' /></li><li id='field_850_23' class='gfield  gsection' ><h2 class='gsection_title'> Passenger #1: Name Information</h2></li><li id='field_850_2' class='gfield' ><label class='gfield_label' for='input_850_2'>Prefix</label><div class='ginput_container'><select name='input_2' id='input_850_2'  class='medium gfield_select' tabindex='1' ><option value='Please select one...' >Please select one...</option><option value='Msgr.' >Msgr.</option><option value='Fr.' >Fr.</option><option value='Dr.' >Dr.</option><option value='Mr.' >Mr.</option><option value='Mrs.' >Mrs.</option><option value='Ms.' >Ms.</option></select></div></li><li id='field_850_1' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_850_1'>First Name<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_1' id='input_850_1' type='text' value='' class='medium'  tabindex='2'  /></div></li><li id='field_850_4' class='gfield' ><label class='gfield_label' for='input_850_4'>Middle Name or Initial (As it appears on passport)</label><div class='ginput_container'><input name='input_4' id='input_850_4' type='text' value='' class='medium'  tabindex='3'  /></div></li><li id='field_850_3' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_850_3'>Last Name<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_3' id='input_850_3' type='text' value='' class='medium'  tabindex='4'  /></div></li><li id='field_850_5' class='gfield' ><label class='gfield_label' for='input_850_5'>Suffix</label><div class='ginput_container'><input name='input_5' id='input_850_5' type='text' value='' class='medium'  tabindex='5'  /></div></li><li id='field_850_52' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_7' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #1: Contact Information</h2></li><li id='field_850_14' class='gfield' ><label class='gfield_label' for='input_850_14'>Email Address</label><div class='ginput_container'><input name='input_14' id='input_850_14' type='text' value='' class='medium'  tabindex='6'  /></div></li><li id='field_850_15' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_850_15_1'>Address Information<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container' id='input_850_15'><span class='ginput_full' id='input_850_15_1_container'><input type='text' name='input_15.1' id='input_850_15_1' value='' tabindex='7' /><label for='input_850_15_1' id='input_850_15_1_label'>Street Address</label></span><span class='ginput_full' id='input_850_15_2_container' ><input type='text' name='input_15.2' id='input_850_15_2' value='' tabindex='8' /><label for='input_850_15_2' id='input_850_15_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_850_15_3_container'><input type='text' name='input_15.3' id='input_850_15_3' value='' tabindex='9' /><label for='input_850_15_3' id='input_850_15.3_label'>City</label></span><span class='ginput_right' id='input_850_15_4_container' ><select name='input_15.4' id='input_850_15.4' tabindex='10'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New 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Forces Pacific' >Armed Forces Pacific</option></select><label for='input_850_15.4' id='input_850_15_4_label'>State</label></span><span class='ginput_left' id='input_850_15_5_container'><input type='text' name='input_15.5' id='input_850_15_5' value='' tabindex='12' /><label for='input_850_15_5' id='input_850_15_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_850_15_6' value='United States'/></div></li><li id='field_850_16' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_850_16'>Phone (1)<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_16' id='input_850_16' type='text' value='' class='medium' tabindex='13' /></div></li><li id='field_850_17' class='gfield' ><label class='gfield_label' for='input_850_17'>Phone (2)</label><div class='ginput_container'><input name='input_17' id='input_850_17' type='text' value='' class='medium' tabindex='14' /></div></li><li id='field_850_63' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_62' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #1: Passport Information</h2></li><li id='field_850_47' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_850_47'>Do you have a passport?<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_47' id='input_850_47' onchange='gf_apply_rules(850,[64,68]);' class='medium gfield_select' tabindex='15' ><option value='' selected='selected'>Please select...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_850_18' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_850_18'>Date of Birth<span class='gfield_required'>*</span></label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_850_18'><input type='text' maxlength='2' name='input_18[]' id='input_850_18.1' value='' tabindex='16' /><label for='input_850_18.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_850_18'><input type='text' maxlength='2' name='input_18[]' id='input_850_18.2' value='' tabindex='17' /><label for='input_850_18.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_850_18'><input type='text' maxlength='4' name='input_18[]' id='input_850_18.3' value='' tabindex='18' /><label for='input_850_18.3'>YYYY</label></div></div></li><li id='field_850_20' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_850_20'>Gender<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_20' id='input_850_20'  class='medium gfield_select' tabindex='19' ><option value='' selected='selected'>Select one...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_850_64' class='gfield' style='display:none;'><label class='gfield_label' for='input_850_64'>Passport Number</label><div class='ginput_container'><input name='input_64' id='input_850_64' type='text' value='' class='small'  tabindex='20'  /></div></li><li id='field_850_68' class='gfield' style='display:none;'><label class='gfield_label' for='input_850_68'>Country of Issuance</label><div class='ginput_container'><select name='input_68' id='input_850_68'  class='medium gfield_select' tabindex='21' ><option value='Select one...' >Select one...</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_850_149' class='gfield' ><label class='gfield_label' for='input_850_149'>Date of Expiration</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_850_149'><input type='text' maxlength='2' name='input_149[]' id='input_850_149.1' value='' tabindex='22' /><label for='input_850_149.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_850_149'><input type='text' maxlength='2' name='input_149[]' id='input_850_149.2' value='' tabindex='23' /><label for='input_850_149.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_850_149'><input type='text' maxlength='4' name='input_149[]' id='input_850_149.3' value='' tabindex='24' /><label for='input_850_149.3'>YYYY</label></div></div></li><li id='field_850_70' class='gfield' ><label class='gfield_label' for='input_850_70'>Upload Passport Image</label><div class='ginput_container'><input name='input_70' id='input_850_70' type='file' value='' size='20' class='medium' tabindex='25' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_850_54' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_24' class='gfield  gsection' ><h2 class='gsection_title'>Passenger  #1: Emergency Contact Information</h2></li><li id='field_850_26' class='gfield' ><label class='gfield_label' for='input_850_26.3'>Name</label><div class='ginput_complex ginput_container' id='input_850_26'><span id='input_850_26_3_container' class='ginput_left'><input type='text' name='input_26.3' id='input_850_26_3' value='' tabindex='26' /><label for='input_850_26_3'>First</label></span><span id='input_850_26_6_container' class='ginput_right'><input type='text' name='input_26.6' id='input_850_26_6' value='' tabindex='27' /><label for='input_850_26_6'>Last</label></span></div></li><li id='field_850_27' class='gfield' ><label class='gfield_label' for='input_850_27'>Phone (1)</label><div class='ginput_container'><input name='input_27' id='input_850_27' type='text' value='' class='medium' tabindex='28' /></div></li><li id='field_850_28' class='gfield' ><label class='gfield_label' for='input_850_28'>Phone (2)</label><div class='ginput_container'><input name='input_28' id='input_850_28' type='text' value='' class='medium' tabindex='29' /></div></li><li id='field_850_29' class='gfield' ><label class='gfield_label' for='input_850_29'>Relationship</label><div class='ginput_container'><input name='input_29' id='input_850_29' type='text' value='' class='medium'  tabindex='30'  /></div></li><li id='field_850_49' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_21' class='gfield  gsection' ><h2 class='gsection_title'>Special Trip Details and Requests</h2></li><li id='field_850_60' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_850_60'>Departure Airport<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_60' id='input_850_60' type='text' value='' class='medium'  tabindex='31'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_850_85' class='gfield' ><label class='gfield_label' for='input_850_85'>Seating Preference</label><div class='ginput_container'><select name='input_85' id='input_850_85'  class='medium gfield_select' tabindex='32' ><option value='Select below...' >Select below...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_850_22' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_850_22'><li class='gchoice_22_1'><input name='input_22.1' type='checkbox'  value='*Special dietary concerns / requests'  id='choice_22_1' tabindex='33'  /><label for='choice_22_1'>*Special dietary concerns / requests</label></li><li class='gchoice_22_2'><input name='input_22.2' type='checkbox'  value='Wheelchair requirement'  id='choice_22_2' tabindex='34'  /><label for='choice_22_2'>Wheelchair requirement</label></li><li class='gchoice_22_3'><input name='input_22.3' type='checkbox'  value='Others (please contact me)'  id='choice_22_3' tabindex='35'  /><label for='choice_22_3'>Others (please contact me)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_850_145' class='gfield' ><label class='gfield_label' for='input_850_145'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_145' id='input_850_145' type='text' value='' class='medium'  tabindex='36'  /></div></li><li id='field_850_25' class='gfield' ><label class='gfield_label' for='input_850_25'>I would like to travel and/or room with these people:</label><div class='ginput_container'><textarea name='input_25' id='input_850_25' class='textarea small' tabindex='37'  rows='10' cols='50'></textarea></div></li><li id='field_850_126' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_150' class='gfield' ><label class='gfield_label'>If registering a second passenger please check box.</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_850_150'><li class='gchoice_150_1'><input name='input_150.1' type='checkbox' onclick='gf_apply_rules(850,[127,129,129,121,139,121,139,128,128,123,122,124,125,140,123,122,124,125,140,130,130,131,132,133,146,147,148,134,141,131,132,133,146,147,148,134,141,135,135,143,136,137,138,142,143,136,137,138,142,30,30,31,32,33,34,48,31,32,33,34,48]);' value='' checked='checked' id='choice_150_1' tabindex='38'  /><label for='choice_150_1'></label></li></ul></div></li><li id='field_850_127' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_129' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Name Information</h2></li><li id='field_850_121' class='gfield' ><label class='gfield_label' for='input_850_121.3'>Name as it appears on Passport</label><div class='ginput_container'><input name='input_121' id='input_850_121' type='text' value='' class='medium' tabindex='39' /></div></li><li id='field_850_139' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_128' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Contact Information (If different from Passenger #1)</h2></li><li id='field_850_123' class='gfield' ><label class='gfield_label' for='input_850_123'>Passenger #2: Email Address</label><div class='ginput_container'><input name='input_123' id='input_850_123' type='text' value='' class='medium'  tabindex='40'  /></div></li><li id='field_850_122' class='gfield' ><label class='gfield_label' for='input_850_122_1'>Passenger #2: Address</label><div class='ginput_complex ginput_container' id='input_850_122'><span class='ginput_full' id='input_850_122_1_container'><input type='text' name='input_122.1' id='input_850_122_1' value='' tabindex='41' /><label for='input_850_122_1' id='input_850_122_1_label'>Street Address</label></span><span class='ginput_full' id='input_850_122_2_container' ><input type='text' name='input_122.2' id='input_850_122_2' value='' tabindex='42' /><label for='input_850_122_2' id='input_850_122_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_850_122_3_container'><input type='text' name='input_122.3' id='input_850_122_3' value='' tabindex='43' /><label for='input_850_122_3' id='input_850_122.3_label'>City</label></span><span class='ginput_right' id='input_850_122_4_container' ><select name='input_122.4' id='input_850_122.4' tabindex='44'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_850_122.4' id='input_850_122_4_label'>State</label></span><span class='ginput_left' id='input_850_122_5_container'><input type='text' name='input_122.5' id='input_850_122_5' value='' tabindex='46' /><label for='input_850_122_5' id='input_850_122_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_122.6' id='input_850_122_6' value='United States'/></div></li><li id='field_850_124' class='gfield' ><label class='gfield_label' for='input_850_124'>Passenger #2: Phone (1)</label><div class='ginput_container'><input name='input_124' id='input_850_124' type='text' value='' class='medium' tabindex='47' /></div></li><li id='field_850_125' class='gfield' ><label class='gfield_label' for='input_850_125'>Passenger #2: Phone (2)</label><div class='ginput_container'><input name='input_125' id='input_850_125' type='text' value='' class='medium' tabindex='48' /></div></li><li id='field_850_140' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_130' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Passport Information</h2></li><li id='field_850_131' class='gfield' ><label class='gfield_label' for='input_850_131'>Do you have a Passport?</label><div class='ginput_container'><select name='input_131' id='input_850_131'  class='small gfield_select' tabindex='49' ><option value='Please select ...' >Please select ...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_850_132' class='gfield' ><label class='gfield_label' for='input_850_132'>Date of Birth</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_850_132'><input type='text' maxlength='2' name='input_132[]' id='input_850_132.1' value='' tabindex='50' /><label for='input_850_132.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_850_132'><input type='text' maxlength='2' name='input_132[]' id='input_850_132.2' value='' tabindex='51' /><label for='input_850_132.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_850_132'><input type='text' maxlength='4' name='input_132[]' id='input_850_132.3' value='' tabindex='52' /><label for='input_850_132.3'>YYYY</label></div></div></li><li id='field_850_133' class='gfield' ><label class='gfield_label' for='input_850_133'>Gender</label><div class='ginput_container'><select name='input_133' id='input_850_133'  class='small gfield_select' tabindex='53' ><option value='Please select ...' >Please select ...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_850_146' class='gfield' ><label class='gfield_label' for='input_850_146'>Passport Number</label><div class='ginput_container'><input name='input_146' id='input_850_146' type='text' value='' class='medium'  tabindex='54'  /></div></li><li id='field_850_147' class='gfield' ><label class='gfield_label' for='input_850_147'>Country of Issuance:</label><div class='ginput_container'><select name='input_147' id='input_850_147'  class='medium gfield_select' tabindex='55' ><option value='Please select...' >Please select...</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_850_148' class='gfield' ><label class='gfield_label' for='input_850_148'>Date of Expiration</label><div class='ginput_container'><input name='input_148' id='input_850_148' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='56' /> </div><input type='hidden' id='gforms_calendar_icon_input_850_148' class='gform_hidden' value='http://www.proximotravel.com/website/wp-content/plugins/gravityforms/images/calendar.png'/></li><li id='field_850_134' class='gfield' ><label class='gfield_label' for='input_850_134'>Upload Passport Image</label><div class='ginput_container'><input name='input_134' id='input_850_134' type='file' value='' size='20' class='medium' tabindex='57' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_850_141' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_135' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Special Trip Details &amp; Requests</h2></li><li id='field_850_143' class='gfield' ><label class='gfield_label' for='input_850_143'>Passenger #2: Departure Airport</label><div class='ginput_container'><input name='input_143' id='input_850_143' type='text' value='' class='medium'  tabindex='58'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_850_136' class='gfield' ><label class='gfield_label' for='input_850_136'>Seat Preferences</label><div class='ginput_container'><select name='input_136' id='input_850_136'  class='medium gfield_select' tabindex='59' ><option value='Select below ...' >Select below ...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_850_137' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_850_137'><li class='gchoice_137_1'><input name='input_137.1' type='checkbox'  value='*Special dietary concernes/requests'  id='choice_137_1' tabindex='60'  /><label for='choice_137_1'>*Special dietary concernes/requests</label></li><li class='gchoice_137_2'><input name='input_137.2' type='checkbox'  value='Wheelchair requirements'  id='choice_137_2' tabindex='61'  /><label for='choice_137_2'>Wheelchair requirements</label></li><li class='gchoice_137_3'><input name='input_137.3' type='checkbox'  value='Others (Please contact me.)'  id='choice_137_3' tabindex='62'  /><label for='choice_137_3'>Others (Please contact me.)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_850_138' class='gfield' ><label class='gfield_label' for='input_850_138'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_138' id='input_850_138' type='text' value='' class='medium'  tabindex='63'  /></div></li><li id='field_850_142' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_30' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Emergency Contact Information </h2></li><li id='field_850_31' class='gfield' ><label class='gfield_label' for='input_850_31.3'>Name</label><div class='ginput_complex ginput_container' id='input_850_31'><span id='input_850_31_3_container' class='ginput_left'><input type='text' name='input_31.3' id='input_850_31_3' value='' tabindex='64' /><label for='input_850_31_3'>First</label></span><span id='input_850_31_6_container' class='ginput_right'><input type='text' name='input_31.6' id='input_850_31_6' value='' tabindex='65' /><label for='input_850_31_6'>Last</label></span></div></li><li id='field_850_32' class='gfield' ><label class='gfield_label' for='input_850_32'>Phone (1)</label><div class='ginput_container'><input name='input_32' id='input_850_32' type='text' value='' class='medium' tabindex='66' /></div></li><li id='field_850_33' class='gfield' ><label class='gfield_label' for='input_850_33'>Phone (2)</label><div class='ginput_container'><input name='input_33' id='input_850_33' type='text' value='' class='medium' tabindex='67' /></div></li><li id='field_850_34' class='gfield' ><label class='gfield_label' for='input_850_34'>Relationship</label><div class='ginput_container'><input name='input_34' id='input_850_34' type='text' value='' class='medium'  tabindex='68'  /></div></li><li id='field_850_48' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_850_38' class='gfield  gsection' ><h2 class='gsection_title'>Purchasing Options</h2><div class='gsection_description'>In order to register and save your place on the trip, a 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Payment in full must be received at 857 West Boylston St. Worcester, MA 01606, 90 days prior to trip date.</div></li><li id='field_850_119' class='gfield           gfield_price gfield_price_850_119 gfield_product_850_119' ><label class='gfield_label' for='input_850_119'>*Total Trip Price</label><div class='ginput_container'><input type='hidden' name='input_119.1' value='*Total Trip Price' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_850_119'>$4,824.97</span><input type='hidden' name='input_119.2' id='ginput_base_price_850_119' class='gform_hidden' value='$4,824.97'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_119.3' value='' id='ginput_quantity_850_119' class='ginput_quantity' size='10' tabindex='69'/></div><div class='gfield_description'>* There is NO 3% credit/debit card surcharge for the initial deposit or travel cancellation protection. 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style='display:none;'><label class='gfield_label' for='input_850_98'>Credit Card or Debit Card Number</label><div class='ginput_container'><input name='input_98' id='input_850_98' type='text' value='' class='medium' tabindex='76' /></div></li><li id='field_850_99' class='gfield' style='display:none;'><label class='gfield_label' for='input_850_99'>CVV</label><div class='ginput_container'><input name='input_99' id='input_850_99' type='text' value='' class='small' tabindex='77' /></div></li><li id='field_850_100' class='gfield' style='display:none;'><label class='gfield_label' for='input_850_100'>Expiration Month</label><div class='ginput_container'><select name='input_100' id='input_850_100'  class='small gfield_select' tabindex='78' ><option value='01' >January</option><option value='02' >February</option><option value='03' >March</option><option value='04' >April</option><option value='05' >May</option><option value='06' >June</option><option value='07' >July</option><option value='08' 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<hr /></li><li id='field_850_111' class='gfield  gsection' ><h2 class='gsection_title'>No Liability Agreement</h2></li><li id='field_850_95' class='gfield               gfield_contains_required' ><label class='gfield_label'>Checking this box means that I agree that no liability is assumed by Antoine Nachef, Proximo Travel, LLC or employees of Proximo Travel, LLC for injuries to person(s) or damage to property while on any trip hosted by Proximo Travel, LLC.<span class='gfield_required'>*</span></label><div class='ginput_container'><ul class='gfield_checkbox' id='input_850_95'><li class='gchoice_95_1'><input name='input_95.1' type='checkbox'  value='I Agree'  id='choice_95_1' tabindex='89'  /><label for='choice_95_1'>I Agree</label></li></ul></div></li><li id='field_850_102' class='gfield     gform_hidden' ><input name='input_102' id='input_850_102' type='hidden' class='gform_hidden' value='' /></li>
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		</item>
		<item>
		<title>Fr. Hritsko, William &#8211; Sacred Heart Church, Coshocton, OH &#8211; IR (2012, Sept 8-16)</title>
		<link>http://www.proximotravel.com/priest-trip/fr-hritsko-william-sacred-heart-church-coshocton-oh-ir-2012-sept-8-16/</link>
		<comments>http://www.proximotravel.com/priest-trip/fr-hritsko-william-sacred-heart-church-coshocton-oh-ir-2012-sept-8-16/#comments</comments>
		<pubDate>Wed, 22 Feb 2012 02:39:14 +0000</pubDate>
		<dc:creator>Carrie Etzel</dc:creator>
				<category><![CDATA[Italy Regular - Priest Trips]]></category>
		<category><![CDATA[Priest Trips]]></category>

		<guid isPermaLink="false">http://www.proximotravel.com/?p=7996</guid>
		<description><![CDATA[Rome • Tuscany • Florence • Assisi • Venice Fr. William Hritsko, Pastor Sacred Heart Church, Coshocton, OH Dates in 2012 September 08 &#8211; 16 $3,599 9 Days Airfare included &#160;]]></description>
			<content:encoded><![CDATA[<h3 style="text-align: center;">Rome • Tuscany • Florence • Assisi • Venice</h3>
<hr />
<h2>Fr. William Hritsko, Pastor<br />
Sacred Heart Church, Coshocton, OH</h2>
<h3>Dates in 2012</h3>
<ul>
<li>September 08 &#8211; 16</li>
<li>$3,599 9 Days</li>
<li>Airfare included</li>
</ul>
<p>&nbsp;</p>

                <div class='gform_wrapper' id='gform_wrapper_821' style='display:none'><form method='post' enctype='multipart/form-data'  id='gform_821'  action='/feed/'>
                        <div class='gform_heading'>
                            <h3 class='gform_title'>Italy Regular (2012, Sept. 08-16) - Trip Registration</h3>
                            <span class='gform_description'>Please fill out the form below with your details to reserve your trip now.</span>
                        </div>
                        <div class='gform_body'>
                            <ul id='gform_fields_821' class='gform_fields top_label'><li id='field_821_50' class='gfield     gform_hidden' ><input name='input_50' id='input_821_50' type='hidden' class='gform_hidden' value='Fr. Hritsko, William - Sacred Heart Church, Coshocton, OH - IR (2012, Sept 8-16)' /></li><li id='field_821_55' class='gfield     gform_hidden' ><input name='input_55' id='input_821_55' type='hidden' class='gform_hidden' value='02/22/2012' /></li><li id='field_821_23' class='gfield  gsection' ><h2 class='gsection_title'> Passenger #1: Name Information</h2></li><li id='field_821_2' class='gfield' ><label class='gfield_label' for='input_821_2'>Prefix</label><div class='ginput_container'><select name='input_2' id='input_821_2'  class='medium gfield_select' tabindex='1' ><option value='Please select one...' >Please select one...</option><option value='Msgr.' >Msgr.</option><option value='Fr.' >Fr.</option><option value='Dr.' >Dr.</option><option value='Mr.' >Mr.</option><option value='Mrs.' >Mrs.</option><option value='Ms.' >Ms.</option></select></div></li><li id='field_821_1' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_821_1'>First Name<span 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id='field_821_52' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_7' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #1: Contact Information</h2></li><li id='field_821_14' class='gfield' ><label class='gfield_label' for='input_821_14'>Email Address</label><div class='ginput_container'><input name='input_14' id='input_821_14' type='text' value='' class='medium'  tabindex='6'  /></div></li><li id='field_821_15' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_821_15_1'>Address Information<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container' id='input_821_15'><span class='ginput_full' id='input_821_15_1_container'><input type='text' name='input_15.1' id='input_821_15_1' value='' tabindex='7' /><label for='input_821_15_1' id='input_821_15_1_label'>Street Address</label></span><span class='ginput_full' id='input_821_15_2_container' ><input type='text' name='input_15.2' id='input_821_15_2' value='' tabindex='8' /><label for='input_821_15_2' id='input_821_15_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_821_15_3_container'><input type='text' name='input_15.3' id='input_821_15_3' value='' tabindex='9' /><label for='input_821_15_3' id='input_821_15.3_label'>City</label></span><span class='ginput_right' id='input_821_15_4_container' ><select name='input_15.4' id='input_821_15.4' tabindex='10'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option 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Forces Pacific' >Armed Forces Pacific</option></select><label for='input_821_15.4' id='input_821_15_4_label'>State</label></span><span class='ginput_left' id='input_821_15_5_container'><input type='text' name='input_15.5' id='input_821_15_5' value='' tabindex='12' /><label for='input_821_15_5' id='input_821_15_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_821_15_6' value='United States'/></div></li><li id='field_821_16' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_821_16'>Phone (1)<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_16' id='input_821_16' type='text' value='' class='medium' tabindex='13' /></div></li><li id='field_821_17' class='gfield' ><label class='gfield_label' for='input_821_17'>Phone (2)</label><div class='ginput_container'><input name='input_17' id='input_821_17' type='text' value='' class='medium' tabindex='14' /></div></li><li id='field_821_63' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_62' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #1: Passport Information</h2></li><li id='field_821_47' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_821_47'>Do you have a passport?<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_47' id='input_821_47' onchange='gf_apply_rules(821,[64,68]);' class='medium gfield_select' tabindex='15' ><option value='' selected='selected'>Please select...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_821_18' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_821_18'>Date of Birth<span class='gfield_required'>*</span></label><div class='clear-multi'><div 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value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' 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value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_821_149' class='gfield' ><label class='gfield_label' for='input_821_149'>Date of Expiration</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_821_149'><input type='text' maxlength='2' name='input_149[]' id='input_821_149.1' value='' tabindex='22' /><label for='input_821_149.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_821_149'><input type='text' maxlength='2' name='input_149[]' id='input_821_149.2' value='' tabindex='23' /><label for='input_821_149.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_821_149'><input type='text' maxlength='4' name='input_149[]' id='input_821_149.3' value='' tabindex='24' /><label for='input_821_149.3'>YYYY</label></div></div></li><li id='field_821_70' class='gfield' ><label class='gfield_label' for='input_821_70'>Upload Passport Image</label><div class='ginput_container'><input name='input_70' id='input_821_70' type='file' value='' size='20' class='medium' tabindex='25' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_821_54' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_24' class='gfield  gsection' ><h2 class='gsection_title'>Passenger  #1: Emergency Contact Information</h2></li><li id='field_821_26' class='gfield' ><label class='gfield_label' for='input_821_26.3'>Name</label><div class='ginput_complex ginput_container' id='input_821_26'><span id='input_821_26_3_container' class='ginput_left'><input type='text' name='input_26.3' id='input_821_26_3' value='' tabindex='26' /><label for='input_821_26_3'>First</label></span><span id='input_821_26_6_container' class='ginput_right'><input type='text' name='input_26.6' id='input_821_26_6' value='' tabindex='27' /><label for='input_821_26_6'>Last</label></span></div></li><li id='field_821_27' class='gfield' ><label class='gfield_label' for='input_821_27'>Phone (1)</label><div class='ginput_container'><input name='input_27' id='input_821_27' type='text' value='' class='medium' tabindex='28' /></div></li><li id='field_821_28' class='gfield' ><label class='gfield_label' for='input_821_28'>Phone (2)</label><div class='ginput_container'><input name='input_28' id='input_821_28' type='text' value='' class='medium' tabindex='29' /></div></li><li id='field_821_29' class='gfield' ><label class='gfield_label' for='input_821_29'>Relationship</label><div class='ginput_container'><input name='input_29' id='input_821_29' type='text' value='' class='medium'  tabindex='30'  /></div></li><li id='field_821_49' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_21' class='gfield  gsection' ><h2 class='gsection_title'>Special Trip Details and Requests</h2></li><li id='field_821_60' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_821_60'>Departure Airport<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_60' id='input_821_60' type='text' value='' class='medium'  tabindex='31'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_821_85' class='gfield' ><label class='gfield_label' for='input_821_85'>Seating Preference</label><div class='ginput_container'><select name='input_85' id='input_821_85'  class='medium gfield_select' tabindex='32' ><option value='Select below...' >Select below...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_821_22' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_821_22'><li class='gchoice_22_1'><input name='input_22.1' type='checkbox'  value='*Special dietary concerns / requests'  id='choice_22_1' tabindex='33'  /><label for='choice_22_1'>*Special dietary concerns / requests</label></li><li class='gchoice_22_2'><input name='input_22.2' type='checkbox'  value='Wheelchair requirement'  id='choice_22_2' tabindex='34'  /><label for='choice_22_2'>Wheelchair requirement</label></li><li class='gchoice_22_3'><input name='input_22.3' type='checkbox'  value='Others (please contact me)'  id='choice_22_3' tabindex='35'  /><label for='choice_22_3'>Others (please contact me)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_821_145' class='gfield' ><label class='gfield_label' for='input_821_145'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_145' id='input_821_145' type='text' value='' class='medium'  tabindex='36'  /></div></li><li id='field_821_25' class='gfield' ><label class='gfield_label' for='input_821_25'>I would like to travel and/or room with these people:</label><div class='ginput_container'><textarea name='input_25' id='input_821_25' class='textarea small' tabindex='37'  rows='10' cols='50'></textarea></div></li><li id='field_821_126' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_150' class='gfield' ><label class='gfield_label'>If registering a second passenger please check box.</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_821_150'><li class='gchoice_150_1'><input name='input_150.1' type='checkbox' onclick='gf_apply_rules(821,[127,129,129,121,139,121,139,128,128,123,122,124,125,140,123,122,124,125,140,130,130,131,132,133,146,147,148,134,141,131,132,133,146,147,148,134,141,135,135,143,136,137,138,142,143,136,137,138,142,30,30,31,32,33,34,48,31,32,33,34,48]);' value='' checked='checked' id='choice_150_1' tabindex='38'  /><label for='choice_150_1'></label></li></ul></div></li><li id='field_821_127' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_129' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Name Information</h2></li><li id='field_821_121' class='gfield' ><label class='gfield_label' for='input_821_121.3'>Name as it appears on Passport</label><div class='ginput_container'><input name='input_121' id='input_821_121' type='text' value='' class='medium' tabindex='39' /></div></li><li id='field_821_139' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_128' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Contact Information (If different from Passenger #1)</h2></li><li id='field_821_123' class='gfield' ><label class='gfield_label' for='input_821_123'>Passenger #2: Email Address</label><div class='ginput_container'><input name='input_123' id='input_821_123' type='text' value='' class='medium'  tabindex='40'  /></div></li><li id='field_821_122' class='gfield' ><label class='gfield_label' for='input_821_122_1'>Passenger #2: Address</label><div class='ginput_complex ginput_container' id='input_821_122'><span class='ginput_full' id='input_821_122_1_container'><input type='text' name='input_122.1' id='input_821_122_1' value='' tabindex='41' /><label for='input_821_122_1' id='input_821_122_1_label'>Street Address</label></span><span class='ginput_full' id='input_821_122_2_container' ><input type='text' name='input_122.2' id='input_821_122_2' value='' tabindex='42' /><label for='input_821_122_2' id='input_821_122_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_821_122_3_container'><input type='text' name='input_122.3' id='input_821_122_3' value='' tabindex='43' /><label for='input_821_122_3' id='input_821_122.3_label'>City</label></span><span class='ginput_right' id='input_821_122_4_container' ><select name='input_122.4' id='input_821_122.4' tabindex='44'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_821_122.4' id='input_821_122_4_label'>State</label></span><span class='ginput_left' id='input_821_122_5_container'><input type='text' name='input_122.5' id='input_821_122_5' value='' tabindex='46' /><label for='input_821_122_5' id='input_821_122_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_122.6' id='input_821_122_6' value='United States'/></div></li><li id='field_821_124' class='gfield' ><label class='gfield_label' for='input_821_124'>Passenger #2: Phone (1)</label><div class='ginput_container'><input name='input_124' id='input_821_124' type='text' value='' class='medium' tabindex='47' /></div></li><li id='field_821_125' class='gfield' ><label class='gfield_label' for='input_821_125'>Passenger #2: Phone (2)</label><div class='ginput_container'><input name='input_125' id='input_821_125' type='text' value='' class='medium' tabindex='48' /></div></li><li id='field_821_140' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_130' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Passport Information</h2></li><li id='field_821_131' class='gfield' ><label class='gfield_label' for='input_821_131'>Do you have a Passport?</label><div class='ginput_container'><select name='input_131' id='input_821_131'  class='small gfield_select' tabindex='49' ><option value='Please select ...' >Please select ...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_821_132' class='gfield' ><label class='gfield_label' for='input_821_132'>Date of Birth</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_821_132'><input type='text' maxlength='2' name='input_132[]' id='input_821_132.1' value='' tabindex='50' /><label for='input_821_132.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_821_132'><input type='text' maxlength='2' name='input_132[]' id='input_821_132.2' value='' tabindex='51' /><label for='input_821_132.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_821_132'><input type='text' maxlength='4' name='input_132[]' id='input_821_132.3' value='' tabindex='52' /><label for='input_821_132.3'>YYYY</label></div></div></li><li id='field_821_133' class='gfield' ><label class='gfield_label' for='input_821_133'>Gender</label><div class='ginput_container'><select name='input_133' id='input_821_133'  class='small gfield_select' tabindex='53' ><option value='Please select ...' >Please select ...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_821_146' class='gfield' ><label class='gfield_label' for='input_821_146'>Passport Number</label><div class='ginput_container'><input name='input_146' id='input_821_146' type='text' value='' class='medium'  tabindex='54'  /></div></li><li id='field_821_147' class='gfield' ><label class='gfield_label' for='input_821_147'>Country of Issuance:</label><div class='ginput_container'><select name='input_147' id='input_821_147'  class='medium gfield_select' tabindex='55' ><option value='Please select...' >Please select...</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_821_148' class='gfield' ><label class='gfield_label' for='input_821_148'>Date of Expiration</label><div class='ginput_container'><input name='input_148' id='input_821_148' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='56' /> </div><input type='hidden' id='gforms_calendar_icon_input_821_148' class='gform_hidden' value='http://www.proximotravel.com/website/wp-content/plugins/gravityforms/images/calendar.png'/></li><li id='field_821_134' class='gfield' ><label class='gfield_label' for='input_821_134'>Upload Passport Image</label><div class='ginput_container'><input name='input_134' id='input_821_134' type='file' value='' size='20' class='medium' tabindex='57' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_821_141' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_135' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Special Trip Details &amp; Requests</h2></li><li id='field_821_143' class='gfield' ><label class='gfield_label' for='input_821_143'>Passenger #2: Departure Airport</label><div class='ginput_container'><input name='input_143' id='input_821_143' type='text' value='' class='medium'  tabindex='58'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_821_136' class='gfield' ><label class='gfield_label' for='input_821_136'>Seat Preferences</label><div class='ginput_container'><select name='input_136' id='input_821_136'  class='medium gfield_select' tabindex='59' ><option value='Select below ...' >Select below ...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_821_137' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_821_137'><li class='gchoice_137_1'><input name='input_137.1' type='checkbox'  value='*Special dietary concernes/requests'  id='choice_137_1' tabindex='60'  /><label for='choice_137_1'>*Special dietary concernes/requests</label></li><li class='gchoice_137_2'><input name='input_137.2' type='checkbox'  value='Wheelchair requirements'  id='choice_137_2' tabindex='61'  /><label for='choice_137_2'>Wheelchair requirements</label></li><li class='gchoice_137_3'><input name='input_137.3' type='checkbox'  value='Others (Please contact me.)'  id='choice_137_3' tabindex='62'  /><label for='choice_137_3'>Others (Please contact me.)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_821_138' class='gfield' ><label class='gfield_label' for='input_821_138'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_138' id='input_821_138' type='text' value='' class='medium'  tabindex='63'  /></div></li><li id='field_821_142' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_30' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Emergency Contact Information </h2></li><li id='field_821_31' class='gfield' ><label class='gfield_label' for='input_821_31.3'>Name</label><div class='ginput_complex ginput_container' id='input_821_31'><span id='input_821_31_3_container' class='ginput_left'><input type='text' name='input_31.3' id='input_821_31_3' value='' tabindex='64' /><label for='input_821_31_3'>First</label></span><span id='input_821_31_6_container' class='ginput_right'><input type='text' name='input_31.6' id='input_821_31_6' value='' tabindex='65' /><label for='input_821_31_6'>Last</label></span></div></li><li id='field_821_32' class='gfield' ><label class='gfield_label' for='input_821_32'>Phone (1)</label><div class='ginput_container'><input name='input_32' id='input_821_32' type='text' value='' class='medium' tabindex='66' /></div></li><li id='field_821_33' class='gfield' ><label class='gfield_label' for='input_821_33'>Phone (2)</label><div class='ginput_container'><input name='input_33' id='input_821_33' type='text' value='' class='medium' tabindex='67' /></div></li><li id='field_821_34' class='gfield' ><label class='gfield_label' for='input_821_34'>Relationship</label><div class='ginput_container'><input name='input_34' id='input_821_34' type='text' value='' class='medium'  tabindex='68'  /></div></li><li id='field_821_48' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_38' class='gfield  gsection' ><h2 class='gsection_title'>Purchasing Options</h2><div class='gsection_description'>In order to register and save your place on the trip, a $500 non-refundable deposit is required per passenger.  Payment in full must be received at 857 West Boylston St. Worcester, MA 01606, 90 days prior to trip date.</div></li><li id='field_821_119' class='gfield           gfield_price gfield_price_821_119 gfield_product_821_119' ><label class='gfield_label' for='input_821_119'>*Total Trip Price</label><div class='ginput_container'><input type='hidden' name='input_119.1' value='*Total Trip Price' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_821_119'>$3,691.97</span><input type='hidden' name='input_119.2' id='ginput_base_price_821_119' class='gform_hidden' value='$3,691.97'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_119.3' value='' id='ginput_quantity_821_119' class='ginput_quantity' size='10' tabindex='69'/></div><div class='gfield_description'>*There is NO 3% credit/debit card surcharge for the initial deposit or travel cancellation protection. If payment is made in full, the 3% credit/debit card surcharge applies ONLY to the cost of the trip less the deposit and travel cancellation protection (if purchased).
For this trip, the 3% credit/debit surcharge is  $92.97.</div></li><li id='field_821_116' class='gfield           gfield_price gfield_price_821_116 gfield_product_821_116' ><label class='gfield_label' for='input_821_116'>Deposit</label><div class='ginput_container'><input type='hidden' name='input_116.1' value='Deposit' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_821_116'>$500.00</span><input type='hidden' name='input_116.2' id='ginput_base_price_821_116' class='gform_hidden' value='$500.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_116.3' value='' id='ginput_quantity_821_116' class='ginput_quantity' size='10' tabindex='70'/></div></li><li id='field_821_117' class='gfield           gfield_price gfield_price_821_117 gfield_product_821_117' ><label class='gfield_label' for='input_821_117'>Travel Cancellation Protection</label><div class='ginput_container'><input type='hidden' name='input_117.1' value='Travel Cancellation Protection' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_821_117'>$200.00</span><input type='hidden' name='input_117.2' id='ginput_base_price_821_117' class='gform_hidden' value='$200.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_117.3' value='' id='ginput_quantity_821_117' class='ginput_quantity' size='10' tabindex='71'/></div></li><li id='field_821_115' class='gfield           gfield_price gfield_price_821_115 gfield_product_821_115' ><label class='gfield_label' for='input_821_115'>Single Supplement</label><div class='ginput_container'><input type='hidden' name='input_115.1' value='Single Supplement' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_821_115'>$700.00</span><input type='hidden' name='input_115.2' id='ginput_base_price_821_115' class='gform_hidden' value='$700.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_115.3' value='' id='ginput_quantity_821_115' class='ginput_quantity' size='10' tabindex='72'/></div><div class='gfield_description'>If you are traveling by yourself and prefer your own room.</div></li><li id='field_821_96' class='gfield            gfield_price gfield_price_821_96 gfield_donation_821_96' ><label class='gfield_label' for='input_821_96'>Custom Amount</label><div class='ginput_container'><input name='input_96' id='input_821_96' type='text' value='' class='medium' tabindex='73' /></div></li><li id='field_821_46' class='gfield' ><label class='gfield_label' for='input_821_46'>Total</label><div class='ginput_container'><span class='ginput_total ginput_total_821'>$0.00</span><input type='hidden' name='input_46' id='input_821_46' class='gform_hidden'/></div></li><li id='field_821_108' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_73' class='gfield  gsection' ><h2 class='gsection_title'>Payment Information</h2></li><li id='field_821_79' class='gfield' ><label class='gfield_label' for='input_821_79'>Payment Type</label><div class='ginput_container'><select name='input_79' id='input_821_79' onchange='gf_apply_rules(821,[97,98,99,100,101]);' class='medium gfield_select' tabindex='74' ><option value='Credit Card or Debit Card' >Credit Card or Debit Card</option><option value='Money Order' >Money Order</option><option value='Cash' >Cash</option><option value='Check' >Check</option></select></div></li><li id='field_821_97' class='gfield' style='display:none;'><label class='gfield_label' for='input_821_97'>Name On Card</label><div class='ginput_container'><input name='input_97' id='input_821_97' type='text' value='' class='medium'  tabindex='75'  /></div></li><li id='field_821_98' class='gfield' style='display:none;'><label class='gfield_label' for='input_821_98'>Credit Card or Debit Card Number</label><div class='ginput_container'><input name='input_98' id='input_821_98' type='text' value='' class='medium' tabindex='76' /></div></li><li id='field_821_99' class='gfield' style='display:none;'><label class='gfield_label' for='input_821_99'>CVV</label><div class='ginput_container'><input name='input_99' id='input_821_99' type='text' value='' class='small' tabindex='77' /></div></li><li id='field_821_100' class='gfield' style='display:none;'><label class='gfield_label' for='input_821_100'>Expiration Month</label><div class='ginput_container'><select name='input_100' id='input_821_100'  class='small gfield_select' tabindex='78' ><option value='01' >January</option><option value='02' >February</option><option value='03' >March</option><option value='04' >April</option><option value='05' >May</option><option value='06' >June</option><option value='07' >July</option><option value='08' >August</option><option value='09' >September</option><option value='10' >October</option><option value='11' >November</option><option value='12' >December</option></select></div></li><li id='field_821_101' class='gfield' style='display:none;'><label class='gfield_label' for='input_821_101'>Expiration Year</label><div class='ginput_container'><select name='input_101' id='input_821_101'  class='small gfield_select' tabindex='79' ><option value='12' >2012</option><option value='13' >2013</option><option value='14' >2014</option><option value='15' >2015</option><option value='16' >2016</option><option value='17' >2017</option><option value='18' >2018</option><option value='19' >2019</option><option value='20' >2020</option><option value='21' >2021</option><option value='22' >2022</option><option value='23' >2023</option><option value='24' >2024</option><option value='25' >2025</option></select></div></li><li id='field_821_103' class='gfield' ><label class='gfield_label'>Check if Billing Address and Mailing Address are the same.</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_821_103'><li class='gchoice_103_1'><input name='input_103.1' type='checkbox' onclick='gf_apply_rules(821,[77]);' value='Same'  id='choice_103_1' tabindex='80'  /><label for='choice_103_1'>Same</label></li></ul></div></li><li id='field_821_77' class='gfield' ><label class='gfield_label' for='input_821_77_1'>Billing Address (If different from above)</label><div class='ginput_complex ginput_container' id='input_821_77'><span class='ginput_full' id='input_821_77_1_container'><input type='text' name='input_77.1' id='input_821_77_1' value='' tabindex='81' /><label for='input_821_77_1' id='input_821_77_1_label'>Street Address</label></span><span class='ginput_full' id='input_821_77_2_container' ><input type='text' name='input_77.2' id='input_821_77_2' value='' tabindex='82' /><label for='input_821_77_2' id='input_821_77_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_821_77_3_container'><input type='text' name='input_77.3' id='input_821_77_3' value='' tabindex='83' /><label for='input_821_77_3' id='input_821_77.3_label'>City</label></span><span class='ginput_right' id='input_821_77_4_container' ><select name='input_77.4' id='input_821_77.4' tabindex='84'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_821_77.4' id='input_821_77_4_label'>State</label></span><span class='ginput_left' id='input_821_77_5_container'><input type='text' name='input_77.5' id='input_821_77_5' value='' tabindex='86' /><label for='input_821_77_5' id='input_821_77_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_77.6' id='input_821_77_6' value='United States'/></div></li><li id='field_821_109' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_112' class='gfield  gsection' ><h2 class='gsection_title'>Miscellaneous</h2></li><li id='field_821_86' class='gfield' ><label class='gfield_label' for='input_821_86'>Additional Comments</label><div class='ginput_container'><textarea name='input_86' id='input_821_86' class='textarea medium' tabindex='87'  rows='10' cols='50'></textarea></div></li><li id='field_821_69' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_821_67' class='gfield' ><label class='gfield_label' for='input_821_67'>How did you hear about Proximo Travel?</label><div class='ginput_container'><input name='input_67' id='input_821_67' type='text' value='' class='large'  tabindex='88'  /></div></li><li id='field_821_110' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div>
<hr /></li><li id='field_821_111' class='gfield  gsection' ><h2 class='gsection_title'>No Liability Agreement</h2></li><li id='field_821_95' class='gfield               gfield_contains_required' ><label class='gfield_label'>Checking this box means that I agree that no liability is assumed by Antoine Nachef, Proximo Travel, LLC or employees of Proximo Travel, LLC for injuries to person(s) or damage to property while on any trip hosted by Proximo Travel, LLC.<span class='gfield_required'>*</span></label><div class='ginput_container'><ul class='gfield_checkbox' id='input_821_95'><li class='gchoice_95_1'><input name='input_95.1' type='checkbox'  value='I Agree'  id='choice_95_1' tabindex='89'  /><label for='choice_95_1'>I Agree</label></li></ul></div></li><li id='field_821_102' class='gfield     gform_hidden' ><input name='input_102' id='input_821_102' type='hidden' class='gform_hidden' value='' /></li>
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		</item>
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		<title>Fr. Denk, Michael &#8211; St. Joseph&#8217;s Parish, Amherst, OH &#8211; HL (2012, October 29-November 8)</title>
		<link>http://www.proximotravel.com/priest-trip/fr-denk-michael-st-josephs-parish-amherst-oh-hl-2012-october-29-november-8/</link>
		<comments>http://www.proximotravel.com/priest-trip/fr-denk-michael-st-josephs-parish-amherst-oh-hl-2012-october-29-november-8/#comments</comments>
		<pubDate>Wed, 22 Feb 2012 02:32:26 +0000</pubDate>
		<dc:creator>Carrie Etzel</dc:creator>
				<category><![CDATA[Holy Land - Priest Trips]]></category>
		<category><![CDATA[Priest Trips]]></category>

		<guid isPermaLink="false">http://www.proximotravel.com/?p=7994</guid>
		<description><![CDATA[Jerusalem • Bethlehem • Nazareth • Galilee • Via Crucis • Last Supper • Gethsemane • Dormition • Nativity Church • Capernaum Fr. Michael Denk, Associate Pastor St. Joseph&#8217;s Parish, Amherst, OH Dates 2012 October 29 &#8211; November 08 $3,999 11 Days Airfare Included]]></description>
			<content:encoded><![CDATA[<h3 style="text-align: center;">Jerusalem • Bethlehem • Nazareth • Galilee • Via Crucis • Last Supper • Gethsemane • Dormition • Nativity Church • Capernaum</h3>
<hr />
<h2>Fr. Michael Denk, Associate Pastor<br />
St. Joseph&#8217;s Parish, Amherst, OH</h2>
<h2>Dates 2012</h2>
<ul>
<li>October 29 &#8211; November 08</li>
<li>$3,999 11 Days</li>
<li>Airfare Included</li>
</ul>

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                            <h3 class='gform_title'>Holy Land (2012, Oct. 29-Nov. 08) - Trip Registration</h3>
                            <span class='gform_description'>Please fill out the form below with your details to reserve your trip now.</span>
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Denk, Michael - St. Joseph&#039;s Parish, Amherst, OH - HL (2012, October 29-November 8)' /></li><li id='field_1103_55' class='gfield     gform_hidden' ><input name='input_55' id='input_1103_55' type='hidden' class='gform_hidden' value='02/22/2012' /></li><li id='field_1103_23' class='gfield  gsection' ><h2 class='gsection_title'> Passenger #1: Name Information</h2></li><li id='field_1103_2' class='gfield' ><label class='gfield_label' for='input_1103_2'>Prefix</label><div class='ginput_container'><select name='input_2' id='input_1103_2'  class='medium gfield_select' tabindex='1' ><option value='Please select one...' >Please select one...</option><option value='Msgr.' >Msgr.</option><option value='Fr.' >Fr.</option><option value='Dr.' >Dr.</option><option value='Mr.' >Mr.</option><option value='Mrs.' >Mrs.</option><option value='Ms.' >Ms.</option></select></div></li><li id='field_1103_1' class='gfield               gfield_contains_required' ><label class='gfield_label' 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value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_1103_149' class='gfield' ><label class='gfield_label' for='input_1103_149'>Date of Expiration</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1103_149'><input type='text' maxlength='2' name='input_149[]' id='input_1103_149.1' value='' tabindex='22' /><label for='input_1103_149.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1103_149'><input type='text' maxlength='2' name='input_149[]' id='input_1103_149.2' value='' tabindex='23' /><label for='input_1103_149.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1103_149'><input type='text' maxlength='4' name='input_149[]' id='input_1103_149.3' value='' tabindex='24' /><label for='input_1103_149.3'>YYYY</label></div></div></li><li id='field_1103_70' class='gfield' ><label class='gfield_label' for='input_1103_70'>Upload Passport Image</label><div class='ginput_container'><input name='input_70' id='input_1103_70' type='file' value='' size='20' class='medium' tabindex='25' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_1103_54' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_24' class='gfield  gsection' ><h2 class='gsection_title'>Passenger  #1: Emergency Contact Information</h2></li><li id='field_1103_26' class='gfield' ><label class='gfield_label' for='input_1103_26.3'>Name</label><div class='ginput_complex ginput_container' id='input_1103_26'><span id='input_1103_26_3_container' class='ginput_left'><input type='text' name='input_26.3' id='input_1103_26_3' value='' tabindex='26' /><label for='input_1103_26_3'>First</label></span><span id='input_1103_26_6_container' class='ginput_right'><input type='text' name='input_26.6' id='input_1103_26_6' value='' tabindex='27' /><label for='input_1103_26_6'>Last</label></span></div></li><li id='field_1103_27' class='gfield' ><label class='gfield_label' for='input_1103_27'>Phone (1)</label><div class='ginput_container'><input name='input_27' id='input_1103_27' type='text' value='' class='medium' tabindex='28' /></div></li><li id='field_1103_28' class='gfield' ><label class='gfield_label' for='input_1103_28'>Phone (2)</label><div class='ginput_container'><input name='input_28' id='input_1103_28' type='text' value='' class='medium' tabindex='29' /></div></li><li id='field_1103_29' class='gfield' ><label class='gfield_label' for='input_1103_29'>Relationship</label><div class='ginput_container'><input name='input_29' id='input_1103_29' type='text' value='' class='medium'  tabindex='30'  /></div></li><li id='field_1103_49' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_21' class='gfield  gsection' ><h2 class='gsection_title'>Special Trip Details and Requests</h2></li><li id='field_1103_60' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1103_60'>Departure Airport<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_60' id='input_1103_60' type='text' value='' class='medium'  tabindex='31'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_1103_85' class='gfield' ><label class='gfield_label' for='input_1103_85'>Seating Preference</label><div class='ginput_container'><select name='input_85' id='input_1103_85'  class='medium gfield_select' tabindex='32' ><option value='Select below...' >Select below...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_1103_22' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1103_22'><li class='gchoice_22_1'><input name='input_22.1' type='checkbox'  value='*Special dietary concerns / requests'  id='choice_22_1' tabindex='33'  /><label for='choice_22_1'>*Special dietary concerns / requests</label></li><li class='gchoice_22_2'><input name='input_22.2' type='checkbox'  value='Wheelchair requirement'  id='choice_22_2' tabindex='34'  /><label for='choice_22_2'>Wheelchair requirement</label></li><li class='gchoice_22_3'><input name='input_22.3' type='checkbox'  value='Others (please contact me)'  id='choice_22_3' tabindex='35'  /><label for='choice_22_3'>Others (please contact me)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_1103_145' class='gfield' ><label class='gfield_label' for='input_1103_145'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_145' id='input_1103_145' type='text' value='' class='medium'  tabindex='36'  /></div></li><li id='field_1103_25' class='gfield' ><label class='gfield_label' for='input_1103_25'>I would like to travel and/or room with these people:</label><div class='ginput_container'><textarea name='input_25' id='input_1103_25' class='textarea small' tabindex='37'  rows='10' cols='50'></textarea></div></li><li id='field_1103_126' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_150' class='gfield' ><label class='gfield_label'>If registering a second passenger please check box.</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1103_150'><li class='gchoice_150_1'><input name='input_150.1' type='checkbox' onclick='gf_apply_rules(1103,[127,129,129,121,139,121,139,128,128,123,122,124,125,140,123,122,124,125,140,130,130,131,132,133,146,147,148,134,141,131,132,133,146,147,148,134,141,135,135,143,136,137,138,142,143,136,137,138,142,30,30,31,32,33,34,48,31,32,33,34,48]);' value='' checked='checked' id='choice_150_1' tabindex='38'  /><label for='choice_150_1'></label></li></ul></div></li><li id='field_1103_127' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_129' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Name Information</h2></li><li id='field_1103_121' class='gfield' ><label class='gfield_label' for='input_1103_121.3'>Name as it appears on Passport</label><div class='ginput_container'><input name='input_121' id='input_1103_121' type='text' value='' class='medium' tabindex='39' /></div></li><li id='field_1103_139' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_128' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Contact Information (If different from Passenger #1)</h2></li><li id='field_1103_123' class='gfield' ><label class='gfield_label' for='input_1103_123'>Passenger #2: Email Address</label><div class='ginput_container'><input name='input_123' id='input_1103_123' type='text' value='' class='medium'  tabindex='40'  /></div></li><li id='field_1103_122' class='gfield' ><label class='gfield_label' for='input_1103_122_1'>Passenger #2: Address</label><div class='ginput_complex ginput_container' id='input_1103_122'><span class='ginput_full' id='input_1103_122_1_container'><input type='text' name='input_122.1' id='input_1103_122_1' value='' tabindex='41' /><label for='input_1103_122_1' id='input_1103_122_1_label'>Street Address</label></span><span class='ginput_full' id='input_1103_122_2_container' ><input type='text' name='input_122.2' id='input_1103_122_2' value='' tabindex='42' /><label for='input_1103_122_2' id='input_1103_122_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_1103_122_3_container'><input type='text' name='input_122.3' id='input_1103_122_3' value='' tabindex='43' /><label for='input_1103_122_3' id='input_1103_122.3_label'>City</label></span><span class='ginput_right' id='input_1103_122_4_container' ><select name='input_122.4' id='input_1103_122.4' tabindex='44'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_1103_122.4' id='input_1103_122_4_label'>State</label></span><span class='ginput_left' id='input_1103_122_5_container'><input type='text' name='input_122.5' id='input_1103_122_5' value='' tabindex='46' /><label for='input_1103_122_5' id='input_1103_122_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_122.6' id='input_1103_122_6' value='United States'/></div></li><li id='field_1103_124' class='gfield' ><label class='gfield_label' for='input_1103_124'>Passenger #2: Phone (1)</label><div class='ginput_container'><input name='input_124' id='input_1103_124' type='text' value='' class='medium' tabindex='47' /></div></li><li id='field_1103_125' class='gfield' ><label class='gfield_label' for='input_1103_125'>Passenger #2: Phone (2)</label><div class='ginput_container'><input name='input_125' id='input_1103_125' type='text' value='' class='medium' tabindex='48' /></div></li><li id='field_1103_140' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_130' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Passport Information</h2></li><li id='field_1103_131' class='gfield' ><label class='gfield_label' for='input_1103_131'>Do you have a Passport?</label><div class='ginput_container'><select name='input_131' id='input_1103_131'  class='small gfield_select' tabindex='49' ><option value='Please select ...' >Please select ...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_1103_132' class='gfield' ><label class='gfield_label' for='input_1103_132'>Date of Birth</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1103_132'><input type='text' maxlength='2' name='input_132[]' id='input_1103_132.1' value='' tabindex='50' /><label for='input_1103_132.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1103_132'><input type='text' maxlength='2' name='input_132[]' id='input_1103_132.2' value='' tabindex='51' /><label for='input_1103_132.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1103_132'><input type='text' maxlength='4' name='input_132[]' id='input_1103_132.3' value='' tabindex='52' /><label for='input_1103_132.3'>YYYY</label></div></div></li><li id='field_1103_133' class='gfield' ><label class='gfield_label' for='input_1103_133'>Gender</label><div class='ginput_container'><select name='input_133' id='input_1103_133'  class='small gfield_select' tabindex='53' ><option value='Please select ...' >Please select ...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_1103_146' class='gfield' ><label class='gfield_label' for='input_1103_146'>Passport Number</label><div class='ginput_container'><input name='input_146' id='input_1103_146' type='text' value='' class='medium'  tabindex='54'  /></div></li><li id='field_1103_147' class='gfield' ><label class='gfield_label' for='input_1103_147'>Country of Issuance:</label><div class='ginput_container'><select name='input_147' id='input_1103_147'  class='medium gfield_select' tabindex='55' ><option value='Please select...' >Please select...</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_1103_148' class='gfield' ><label class='gfield_label' for='input_1103_148'>Date of Expiration</label><div class='ginput_container'><input name='input_148' id='input_1103_148' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='56' /> </div><input type='hidden' id='gforms_calendar_icon_input_1103_148' class='gform_hidden' value='http://www.proximotravel.com/website/wp-content/plugins/gravityforms/images/calendar.png'/></li><li id='field_1103_134' class='gfield' ><label class='gfield_label' for='input_1103_134'>Upload Passport Image</label><div class='ginput_container'><input name='input_134' id='input_1103_134' type='file' value='' size='20' class='medium' tabindex='57' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_1103_141' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_135' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Special Trip Details &amp; Requests</h2></li><li id='field_1103_143' class='gfield' ><label class='gfield_label' for='input_1103_143'>Passenger #2: Departure Airport</label><div class='ginput_container'><input name='input_143' id='input_1103_143' type='text' value='' class='medium'  tabindex='58'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_1103_136' class='gfield' ><label class='gfield_label' for='input_1103_136'>Seat Preferences</label><div class='ginput_container'><select name='input_136' id='input_1103_136'  class='medium gfield_select' tabindex='59' ><option value='Select below ...' >Select below ...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_1103_137' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1103_137'><li class='gchoice_137_1'><input name='input_137.1' type='checkbox'  value='*Special dietary concernes/requests'  id='choice_137_1' tabindex='60'  /><label for='choice_137_1'>*Special dietary concernes/requests</label></li><li class='gchoice_137_2'><input name='input_137.2' type='checkbox'  value='Wheelchair requirements'  id='choice_137_2' tabindex='61'  /><label for='choice_137_2'>Wheelchair requirements</label></li><li class='gchoice_137_3'><input name='input_137.3' type='checkbox'  value='Others (Please contact me.)'  id='choice_137_3' tabindex='62'  /><label for='choice_137_3'>Others (Please contact me.)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_1103_138' class='gfield' ><label class='gfield_label' for='input_1103_138'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_138' id='input_1103_138' type='text' value='' class='medium'  tabindex='63'  /></div></li><li id='field_1103_142' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_30' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Emergency Contact Information </h2></li><li id='field_1103_31' class='gfield' ><label class='gfield_label' for='input_1103_31.3'>Name</label><div class='ginput_complex ginput_container' id='input_1103_31'><span id='input_1103_31_3_container' class='ginput_left'><input type='text' name='input_31.3' id='input_1103_31_3' value='' tabindex='64' /><label for='input_1103_31_3'>First</label></span><span id='input_1103_31_6_container' class='ginput_right'><input type='text' name='input_31.6' id='input_1103_31_6' value='' tabindex='65' /><label for='input_1103_31_6'>Last</label></span></div></li><li id='field_1103_32' class='gfield' ><label class='gfield_label' for='input_1103_32'>Phone (1)</label><div class='ginput_container'><input name='input_32' id='input_1103_32' type='text' value='' class='medium' tabindex='66' /></div></li><li id='field_1103_33' class='gfield' ><label class='gfield_label' for='input_1103_33'>Phone (2)</label><div class='ginput_container'><input name='input_33' id='input_1103_33' type='text' value='' class='medium' tabindex='67' /></div></li><li id='field_1103_34' class='gfield' ><label class='gfield_label' for='input_1103_34'>Relationship</label><div class='ginput_container'><input name='input_34' id='input_1103_34' type='text' value='' class='medium'  tabindex='68'  /></div></li><li id='field_1103_48' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_38' class='gfield  gsection' ><h2 class='gsection_title'>Purchasing Options</h2><div class='gsection_description'>In order to register and save your place on the trip, a $500 non-refundable deposit is required per passenger. Payment in full must be received at 857 West Boylston St. Worcester, MA 01606, 90 days prior to trip date.</div></li><li id='field_1103_119' class='gfield           gfield_price gfield_price_1103_119 gfield_product_1103_119' ><label class='gfield_label' for='input_1103_119'>*Total Trip Price</label><div class='ginput_container'><input type='hidden' name='input_119.1' value='*Total Trip Price' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1103_119'>$4,103.97</span><input type='hidden' name='input_119.2' id='ginput_base_price_1103_119' class='gform_hidden' value='$4,103.97'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_119.3' value='' id='ginput_quantity_1103_119' class='ginput_quantity' size='10' tabindex='69'/></div><div class='gfield_description'>* There is NO 3% credit/debit card surcharge for the initial deposit or travel cancellation protection. If payment is made in full, the 3% credit/debit card surcharge applies ONLY to the cost of the trip less the deposit and travel cancellation protection (if purchased).
For this trip, the 3% credit/debit surcharge is $104.97.</div></li><li id='field_1103_116' class='gfield           gfield_price gfield_price_1103_116 gfield_product_1103_116' ><label class='gfield_label' for='input_1103_116'>Deposit</label><div class='ginput_container'><input type='hidden' name='input_116.1' value='Deposit' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1103_116'>$500.00</span><input type='hidden' name='input_116.2' id='ginput_base_price_1103_116' class='gform_hidden' value='$500.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_116.3' value='' id='ginput_quantity_1103_116' class='ginput_quantity' size='10' tabindex='70'/></div></li><li id='field_1103_117' class='gfield           gfield_price gfield_price_1103_117 gfield_product_1103_117' ><label class='gfield_label' for='input_1103_117'>Travel Cancellation Protection</label><div class='ginput_container'><input type='hidden' name='input_117.1' value='Travel Cancellation Protection' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1103_117'>$200.00</span><input type='hidden' name='input_117.2' id='ginput_base_price_1103_117' class='gform_hidden' value='$200.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_117.3' value='' id='ginput_quantity_1103_117' class='ginput_quantity' size='10' tabindex='71'/></div></li><li id='field_1103_115' class='gfield           gfield_price gfield_price_1103_115 gfield_product_1103_115' ><label class='gfield_label' for='input_1103_115'>Single Supplement</label><div class='ginput_container'><input type='hidden' name='input_115.1' value='Single Supplement' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1103_115'>$700.00</span><input type='hidden' name='input_115.2' id='ginput_base_price_1103_115' class='gform_hidden' value='$700.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_115.3' value='' id='ginput_quantity_1103_115' class='ginput_quantity' size='10' tabindex='72'/></div><div class='gfield_description'>If you are traveling by yourself and prefer your own room.</div></li><li id='field_1103_96' class='gfield            gfield_price gfield_price_1103_96 gfield_donation_1103_96' ><label class='gfield_label' for='input_1103_96'>Custom Amount</label><div class='ginput_container'><input name='input_96' id='input_1103_96' type='text' value='' class='medium' tabindex='73' /></div></li><li id='field_1103_46' class='gfield' ><label class='gfield_label' for='input_1103_46'>Total</label><div class='ginput_container'><span class='ginput_total ginput_total_1103'>$0.00</span><input type='hidden' name='input_46' id='input_1103_46' class='gform_hidden'/></div></li><li id='field_1103_108' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_73' class='gfield  gsection' ><h2 class='gsection_title'>Payment Information</h2></li><li id='field_1103_79' class='gfield' ><label class='gfield_label' for='input_1103_79'>Payment Type</label><div class='ginput_container'><select name='input_79' id='input_1103_79' onchange='gf_apply_rules(1103,[97,98,99,100,101]);' class='medium gfield_select' tabindex='74' ><option value='Credit Card or Debit Card' >Credit Card or Debit Card</option><option value='Money Order' >Money Order</option><option value='Cash' >Cash</option><option value='Check' >Check</option></select></div></li><li id='field_1103_97' class='gfield' style='display:none;'><label class='gfield_label' for='input_1103_97'>Name On Card</label><div class='ginput_container'><input name='input_97' id='input_1103_97' type='text' value='' class='medium'  tabindex='75'  /></div></li><li id='field_1103_98' class='gfield' style='display:none;'><label class='gfield_label' for='input_1103_98'>Credit Card or Debit Card Number</label><div class='ginput_container'><input name='input_98' id='input_1103_98' type='text' value='' class='medium' tabindex='76' /></div></li><li id='field_1103_99' class='gfield' style='display:none;'><label class='gfield_label' for='input_1103_99'>CVV</label><div class='ginput_container'><input name='input_99' id='input_1103_99' type='text' value='' class='small' tabindex='77' /></div></li><li id='field_1103_100' class='gfield' style='display:none;'><label class='gfield_label' for='input_1103_100'>Expiration Month</label><div class='ginput_container'><select name='input_100' id='input_1103_100'  class='small gfield_select' tabindex='78' ><option value='01' >January</option><option value='02' >February</option><option value='03' >March</option><option value='04' >April</option><option value='05' >May</option><option value='06' >June</option><option value='07' >July</option><option value='08' >August</option><option value='09' >September</option><option value='10' >October</option><option value='11' >November</option><option value='12' >December</option></select></div></li><li id='field_1103_101' class='gfield' style='display:none;'><label class='gfield_label' for='input_1103_101'>Expiration Year</label><div class='ginput_container'><select name='input_101' id='input_1103_101'  class='small gfield_select' tabindex='79' ><option value='11' >2011</option><option value='12' >2012</option><option value='13' >2013</option><option value='14' >2014</option><option value='15' >2015</option><option value='16' >2016</option><option value='17' >2017</option><option value='18' >2018</option><option value='19' >2019</option><option value='20' >2020</option><option value='21' >2021</option><option value='22' >2022</option><option value='23' >2023</option><option value='24' >2024</option><option value='25' >2025</option></select></div></li><li id='field_1103_103' class='gfield' ><label class='gfield_label'>Check if Billing Address and Mailing Address are the same.</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1103_103'><li class='gchoice_103_1'><input name='input_103.1' type='checkbox' onclick='gf_apply_rules(1103,[77]);' value='Same'  id='choice_103_1' tabindex='80'  /><label for='choice_103_1'>Same</label></li></ul></div></li><li id='field_1103_77' class='gfield' ><label class='gfield_label' for='input_1103_77_1'>Billing Address (If different from above)</label><div class='ginput_complex ginput_container' id='input_1103_77'><span class='ginput_full' id='input_1103_77_1_container'><input type='text' name='input_77.1' id='input_1103_77_1' value='' tabindex='81' /><label for='input_1103_77_1' id='input_1103_77_1_label'>Street Address</label></span><span class='ginput_full' id='input_1103_77_2_container' ><input type='text' name='input_77.2' id='input_1103_77_2' value='' tabindex='82' /><label for='input_1103_77_2' id='input_1103_77_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_1103_77_3_container'><input type='text' name='input_77.3' id='input_1103_77_3' value='' tabindex='83' /><label for='input_1103_77_3' id='input_1103_77.3_label'>City</label></span><span class='ginput_right' id='input_1103_77_4_container' ><select name='input_77.4' id='input_1103_77.4' tabindex='84'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_1103_77.4' id='input_1103_77_4_label'>State</label></span><span class='ginput_left' id='input_1103_77_5_container'><input type='text' name='input_77.5' id='input_1103_77_5' value='' tabindex='86' /><label for='input_1103_77_5' id='input_1103_77_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_77.6' id='input_1103_77_6' value='United States'/></div></li><li id='field_1103_109' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1103_112' class='gfield  gsection' ><h2 class='gsection_title'>Miscellaneous</h2></li><li id='field_1103_86' class='gfield' ><label class='gfield_label' for='input_1103_86'>Additional Comments</label><div class='ginput_container'><textarea name='input_86' id='input_1103_86' class='textarea medium' tabindex='87'  rows='10' cols='50'></textarea></div></li><li id='field_1103_69' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' 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			<wfw:commentRss>http://www.proximotravel.com/priest-trip/fr-denk-michael-st-josephs-parish-amherst-oh-hl-2012-october-29-november-8/feed/</wfw:commentRss>
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		<item>
		<title>Fr. Wesolowski, Victor R. &#8211; St. Rose of Lima Catholic Church, New Lexington, OH &#8211; ILF (2012, Oct 06-18)</title>
		<link>http://www.proximotravel.com/priest-trip/fr-wesolowski-victor-r-st-rose-of-lima-catholic-church-new-lexington-oh-ilf-2012-oct-06-18/</link>
		<comments>http://www.proximotravel.com/priest-trip/fr-wesolowski-victor-r-st-rose-of-lima-catholic-church-new-lexington-oh-ilf-2012-oct-06-18/#comments</comments>
		<pubDate>Wed, 22 Feb 2012 02:25:27 +0000</pubDate>
		<dc:creator>Carrie Etzel</dc:creator>
				<category><![CDATA[Italy, Lourdes, Fatima - Priest Trips]]></category>
		<category><![CDATA[Priest Trips]]></category>

		<guid isPermaLink="false">http://www.proximotravel.com/?p=7992</guid>
		<description><![CDATA[Lourdes • Fatima • Lisbon • Assisi • Florence • Rome • Venice Fr. Victor R. Wesolowski, Parochial Vicar St. Rose of Lima Catholic Church, New Lexington, OH Date in 2012 October 06-18 $4,499 13 Days Airfare Included &#160;]]></description>
			<content:encoded><![CDATA[<h3 style="text-align: center;">Lourdes • Fatima • Lisbon • Assisi • Florence • Rome • Venice</h3>
<hr />
<h2>Fr. Victor R. Wesolowski, Parochial Vicar<br />
St. Rose of Lima Catholic Church, New Lexington, OH</h2>
<h3>Date in 2012</h3>
<ul>
<li>October 06-18</li>
<li>$4,499 13 Days</li>
<li>Airfare Included</li>
</ul>
<p>&nbsp;</p>

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Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_826_15.4' id='input_826_15_4_label'>State</label></span><span class='ginput_left' id='input_826_15_5_container'><input type='text' name='input_15.5' id='input_826_15_5' value='' tabindex='12' /><label for='input_826_15_5' id='input_826_15_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_826_15_6' value='United States'/></div></li><li id='field_826_16' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_826_16'>Phone (1)<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_16' id='input_826_16' type='text' value='' class='medium' tabindex='13' /></div></li><li id='field_826_17' class='gfield' ><label class='gfield_label' for='input_826_17'>Phone (2)</label><div class='ginput_container'><input name='input_17' id='input_826_17' type='text' value='' class='medium' tabindex='14' /></div></li><li id='field_826_63' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_62' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #1: Passport Information</h2></li><li id='field_826_47' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_826_47'>Do you have a passport?<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_47' id='input_826_47' onchange='gf_apply_rules(826,[64,68]);' class='medium gfield_select' tabindex='15' ><option value='' selected='selected'>Please select...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_826_18' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_826_18'>Date of Birth<span class='gfield_required'>*</span></label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_826_18'><input type='text' maxlength='2' name='input_18[]' id='input_826_18.1' value='' tabindex='16' /><label for='input_826_18.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_826_18'><input type='text' maxlength='2' name='input_18[]' id='input_826_18.2' value='' tabindex='17' /><label for='input_826_18.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_826_18'><input type='text' maxlength='4' name='input_18[]' id='input_826_18.3' value='' tabindex='18' /><label for='input_826_18.3'>YYYY</label></div></div></li><li id='field_826_20' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_826_20'>Gender<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_20' id='input_826_20'  class='medium gfield_select' tabindex='19' ><option value='' selected='selected'>Select one...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_826_64' class='gfield' style='display:none;'><label class='gfield_label' for='input_826_64'>Passport Number</label><div class='ginput_container'><input name='input_64' id='input_826_64' type='text' value='' class='small'  tabindex='20'  /></div></li><li id='field_826_68' class='gfield' style='display:none;'><label class='gfield_label' for='input_826_68'>Country of Issuance</label><div class='ginput_container'><select name='input_68' id='input_826_68'  class='medium gfield_select' tabindex='21' ><option value='Select one...' >Select one...</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_826_149' class='gfield' ><label class='gfield_label' for='input_826_149'>Date of Expiration</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_826_149'><input type='text' maxlength='2' name='input_149[]' id='input_826_149.1' value='' tabindex='22' /><label for='input_826_149.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_826_149'><input type='text' maxlength='2' name='input_149[]' id='input_826_149.2' value='' tabindex='23' /><label for='input_826_149.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_826_149'><input type='text' maxlength='4' name='input_149[]' id='input_826_149.3' value='' tabindex='24' /><label for='input_826_149.3'>YYYY</label></div></div></li><li id='field_826_70' class='gfield' ><label class='gfield_label' for='input_826_70'>Upload Passport Image</label><div class='ginput_container'><input name='input_70' id='input_826_70' type='file' value='' size='20' class='medium' tabindex='25' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_826_54' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_24' class='gfield  gsection' ><h2 class='gsection_title'>Passenger  #1: Emergency Contact Information</h2></li><li id='field_826_26' class='gfield' ><label class='gfield_label' for='input_826_26.3'>Name</label><div class='ginput_complex ginput_container' id='input_826_26'><span id='input_826_26_3_container' class='ginput_left'><input type='text' name='input_26.3' id='input_826_26_3' value='' tabindex='26' /><label for='input_826_26_3'>First</label></span><span id='input_826_26_6_container' class='ginput_right'><input type='text' name='input_26.6' id='input_826_26_6' value='' tabindex='27' /><label for='input_826_26_6'>Last</label></span></div></li><li id='field_826_27' class='gfield' ><label class='gfield_label' for='input_826_27'>Phone (1)</label><div class='ginput_container'><input name='input_27' id='input_826_27' type='text' value='' class='medium' tabindex='28' /></div></li><li id='field_826_28' class='gfield' ><label class='gfield_label' for='input_826_28'>Phone (2)</label><div class='ginput_container'><input name='input_28' id='input_826_28' type='text' value='' class='medium' tabindex='29' /></div></li><li id='field_826_29' class='gfield' ><label class='gfield_label' for='input_826_29'>Relationship</label><div class='ginput_container'><input name='input_29' id='input_826_29' type='text' value='' class='medium'  tabindex='30'  /></div></li><li id='field_826_49' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_21' class='gfield  gsection' ><h2 class='gsection_title'>Special Trip Details and Requests</h2></li><li id='field_826_60' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_826_60'>Departure Airport<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_60' id='input_826_60' type='text' value='' class='medium'  tabindex='31'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_826_85' class='gfield' ><label class='gfield_label' for='input_826_85'>Seating Preference</label><div class='ginput_container'><select name='input_85' id='input_826_85'  class='medium gfield_select' tabindex='32' ><option value='Select below...' >Select below...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_826_22' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_826_22'><li class='gchoice_22_1'><input name='input_22.1' type='checkbox'  value='*Special dietary concerns / requests'  id='choice_22_1' tabindex='33'  /><label for='choice_22_1'>*Special dietary concerns / requests</label></li><li class='gchoice_22_2'><input name='input_22.2' type='checkbox'  value='Wheelchair requirement'  id='choice_22_2' tabindex='34'  /><label for='choice_22_2'>Wheelchair requirement</label></li><li class='gchoice_22_3'><input name='input_22.3' type='checkbox'  value='Others (please contact me)'  id='choice_22_3' tabindex='35'  /><label for='choice_22_3'>Others (please contact me)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_826_145' class='gfield' ><label class='gfield_label' for='input_826_145'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_145' id='input_826_145' type='text' value='' class='medium'  tabindex='36'  /></div></li><li id='field_826_25' class='gfield' ><label class='gfield_label' for='input_826_25'>I would like to travel and/or room with these people:</label><div class='ginput_container'><textarea name='input_25' id='input_826_25' class='textarea small' tabindex='37'  rows='10' cols='50'></textarea></div></li><li id='field_826_126' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_150' class='gfield' ><label class='gfield_label'>If registering a second passenger please check box.</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_826_150'><li class='gchoice_150_1'><input name='input_150.1' type='checkbox' onclick='gf_apply_rules(826,[127,129,129,121,139,121,139,128,128,123,122,124,125,140,123,122,124,125,140,130,130,131,132,133,146,147,148,134,141,131,132,133,146,147,148,134,141,135,135,143,136,137,138,142,143,136,137,138,142,30,30,31,32,33,34,48,31,32,33,34,48]);' value='' checked='checked' id='choice_150_1' tabindex='38'  /><label for='choice_150_1'></label></li></ul></div></li><li id='field_826_127' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_129' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Name Information</h2></li><li id='field_826_121' class='gfield' ><label class='gfield_label' for='input_826_121.3'>Name as it appears on Passport</label><div class='ginput_container'><input name='input_121' id='input_826_121' type='text' value='' class='medium' tabindex='39' /></div></li><li id='field_826_139' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_128' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Contact Information (If different from Passenger #1)</h2></li><li id='field_826_123' class='gfield' ><label class='gfield_label' for='input_826_123'>Passenger #2: Email Address</label><div class='ginput_container'><input name='input_123' id='input_826_123' type='text' value='' class='medium'  tabindex='40'  /></div></li><li id='field_826_122' class='gfield' ><label class='gfield_label' for='input_826_122_1'>Passenger #2: Address</label><div class='ginput_complex ginput_container' id='input_826_122'><span class='ginput_full' id='input_826_122_1_container'><input type='text' name='input_122.1' id='input_826_122_1' value='' tabindex='41' /><label for='input_826_122_1' id='input_826_122_1_label'>Street Address</label></span><span class='ginput_full' id='input_826_122_2_container' ><input type='text' name='input_122.2' id='input_826_122_2' value='' tabindex='42' /><label for='input_826_122_2' id='input_826_122_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_826_122_3_container'><input type='text' name='input_122.3' id='input_826_122_3' value='' tabindex='43' /><label for='input_826_122_3' id='input_826_122.3_label'>City</label></span><span class='ginput_right' id='input_826_122_4_container' ><select name='input_122.4' id='input_826_122.4' tabindex='44'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_826_122.4' id='input_826_122_4_label'>State</label></span><span class='ginput_left' id='input_826_122_5_container'><input type='text' name='input_122.5' id='input_826_122_5' value='' tabindex='46' /><label for='input_826_122_5' id='input_826_122_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_122.6' id='input_826_122_6' value='United States'/></div></li><li id='field_826_124' class='gfield' ><label class='gfield_label' for='input_826_124'>Passenger #2: Phone (1)</label><div class='ginput_container'><input name='input_124' id='input_826_124' type='text' value='' class='medium' tabindex='47' /></div></li><li id='field_826_125' class='gfield' ><label class='gfield_label' for='input_826_125'>Passenger #2: Phone (2)</label><div class='ginput_container'><input name='input_125' id='input_826_125' type='text' value='' class='medium' tabindex='48' /></div></li><li id='field_826_140' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_130' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Passport Information</h2></li><li id='field_826_131' class='gfield' ><label class='gfield_label' for='input_826_131'>Do you have a Passport?</label><div class='ginput_container'><select name='input_131' id='input_826_131'  class='small gfield_select' tabindex='49' ><option value='Please select ...' >Please select ...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_826_132' class='gfield' ><label class='gfield_label' for='input_826_132'>Date of Birth</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_826_132'><input type='text' maxlength='2' name='input_132[]' id='input_826_132.1' value='' tabindex='50' /><label for='input_826_132.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_826_132'><input type='text' maxlength='2' name='input_132[]' id='input_826_132.2' value='' tabindex='51' /><label for='input_826_132.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_826_132'><input type='text' maxlength='4' name='input_132[]' id='input_826_132.3' value='' tabindex='52' /><label for='input_826_132.3'>YYYY</label></div></div></li><li id='field_826_133' class='gfield' ><label class='gfield_label' for='input_826_133'>Gender</label><div class='ginput_container'><select name='input_133' id='input_826_133'  class='small gfield_select' tabindex='53' ><option value='Please select ...' >Please select ...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_826_146' class='gfield' ><label class='gfield_label' for='input_826_146'>Passport Number</label><div class='ginput_container'><input name='input_146' id='input_826_146' type='text' value='' class='medium'  tabindex='54'  /></div></li><li id='field_826_147' class='gfield' ><label class='gfield_label' for='input_826_147'>Country of Issuance:</label><div class='ginput_container'><select name='input_147' id='input_826_147'  class='medium gfield_select' tabindex='55' ><option value='Please select...' >Please select...</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_826_148' class='gfield' ><label class='gfield_label' for='input_826_148'>Date of Expiration</label><div class='ginput_container'><input name='input_148' id='input_826_148' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='56' /> </div><input type='hidden' id='gforms_calendar_icon_input_826_148' class='gform_hidden' value='http://www.proximotravel.com/website/wp-content/plugins/gravityforms/images/calendar.png'/></li><li id='field_826_134' class='gfield' ><label class='gfield_label' for='input_826_134'>Upload Passport Image</label><div class='ginput_container'><input name='input_134' id='input_826_134' type='file' value='' size='20' class='medium' tabindex='57' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_826_141' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_135' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Special Trip Details &amp; Requests</h2></li><li id='field_826_143' class='gfield' ><label class='gfield_label' for='input_826_143'>Passenger #2: Departure Airport</label><div class='ginput_container'><input name='input_143' id='input_826_143' type='text' value='' class='medium'  tabindex='58'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_826_136' class='gfield' ><label class='gfield_label' for='input_826_136'>Seat Preferences</label><div class='ginput_container'><select name='input_136' id='input_826_136'  class='medium gfield_select' tabindex='59' ><option value='Select below ...' >Select below ...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_826_137' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_826_137'><li class='gchoice_137_1'><input name='input_137.1' type='checkbox'  value='*Special dietary concernes/requests'  id='choice_137_1' tabindex='60'  /><label for='choice_137_1'>*Special dietary concernes/requests</label></li><li class='gchoice_137_2'><input name='input_137.2' type='checkbox'  value='Wheelchair requirements'  id='choice_137_2' tabindex='61'  /><label for='choice_137_2'>Wheelchair requirements</label></li><li class='gchoice_137_3'><input name='input_137.3' type='checkbox'  value='Others (Please contact me.)'  id='choice_137_3' tabindex='62'  /><label for='choice_137_3'>Others (Please contact me.)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_826_138' class='gfield' ><label class='gfield_label' for='input_826_138'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_138' id='input_826_138' type='text' value='' class='medium'  tabindex='63'  /></div></li><li id='field_826_142' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_30' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #2: Emergency Contact Information </h2></li><li id='field_826_31' class='gfield' ><label class='gfield_label' for='input_826_31.3'>Name</label><div class='ginput_complex ginput_container' id='input_826_31'><span id='input_826_31_3_container' class='ginput_left'><input type='text' name='input_31.3' id='input_826_31_3' value='' tabindex='64' /><label for='input_826_31_3'>First</label></span><span id='input_826_31_6_container' class='ginput_right'><input type='text' name='input_31.6' id='input_826_31_6' value='' tabindex='65' /><label for='input_826_31_6'>Last</label></span></div></li><li id='field_826_32' class='gfield' ><label class='gfield_label' for='input_826_32'>Phone (1)</label><div class='ginput_container'><input name='input_32' id='input_826_32' type='text' value='' class='medium' tabindex='66' /></div></li><li id='field_826_33' class='gfield' ><label class='gfield_label' for='input_826_33'>Phone (2)</label><div class='ginput_container'><input name='input_33' id='input_826_33' type='text' value='' class='medium' tabindex='67' /></div></li><li id='field_826_34' class='gfield' ><label class='gfield_label' for='input_826_34'>Relationship</label><div class='ginput_container'><input name='input_34' id='input_826_34' type='text' value='' class='medium'  tabindex='68'  /></div></li><li id='field_826_48' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_38' class='gfield  gsection' ><h2 class='gsection_title'>Purchasing Options</h2><div class='gsection_description'>In order to register and save your place on the trip,a $500 non-refundable deposit is required per passenger.  Payment in full must be received at 857 West Boylston St. Worcester, MA 01606, 90 days prior to trip date.</div></li><li id='field_826_119' class='gfield           gfield_price gfield_price_826_119 gfield_product_826_119' ><label class='gfield_label' for='input_826_119'>*Total Trip Price</label><div class='ginput_container'><input type='hidden' name='input_119.1' value='*Total Trip Price' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_826_119'>$4,618.97</span><input type='hidden' name='input_119.2' id='ginput_base_price_826_119' class='gform_hidden' value='$4,618.97'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_119.3' value='' id='ginput_quantity_826_119' class='ginput_quantity' size='10' tabindex='69'/></div><div class='gfield_description'>* There is NO 3% credit/debit card surcharge for the initial deposit or travel cancellation protection. If payment is made in full, the 3% credit/debit card surcharge applies ONLY to the cost of the trip less the deposit and travel cancellation protection (if purchased).
For this trip, the 3% credit/debit surcharge is $119.97.</div></li><li id='field_826_116' class='gfield           gfield_price gfield_price_826_116 gfield_product_826_116' ><label class='gfield_label' for='input_826_116'>Deposit</label><div class='ginput_container'><input type='hidden' name='input_116.1' value='Deposit' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_826_116'>$500.00</span><input type='hidden' name='input_116.2' id='ginput_base_price_826_116' class='gform_hidden' value='$500.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_116.3' value='' id='ginput_quantity_826_116' class='ginput_quantity' size='10' tabindex='70'/></div></li><li id='field_826_117' class='gfield           gfield_price gfield_price_826_117 gfield_product_826_117' ><label class='gfield_label' for='input_826_117'>Travel Cancellation Protection</label><div class='ginput_container'><input type='hidden' name='input_117.1' value='Travel Cancellation Protection' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_826_117'>$200.00</span><input type='hidden' name='input_117.2' id='ginput_base_price_826_117' class='gform_hidden' value='$200.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_117.3' value='' id='ginput_quantity_826_117' class='ginput_quantity' size='10' tabindex='71'/></div></li><li id='field_826_115' class='gfield           gfield_price gfield_price_826_115 gfield_product_826_115' ><label class='gfield_label' for='input_826_115'>Single Supplement</label><div class='ginput_container'><input type='hidden' name='input_115.1' value='Single Supplement' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_826_115'>$700.00</span><input type='hidden' name='input_115.2' id='ginput_base_price_826_115' class='gform_hidden' value='$700.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_115.3' value='' id='ginput_quantity_826_115' class='ginput_quantity' size='10' tabindex='72'/></div><div class='gfield_description'>If you are traveling by yourself and prefer your own room.</div></li><li id='field_826_96' class='gfield            gfield_price gfield_price_826_96 gfield_donation_826_96' ><label class='gfield_label' for='input_826_96'>Custom Amount</label><div class='ginput_container'><input name='input_96' id='input_826_96' type='text' value='' class='medium' tabindex='73' /></div></li><li id='field_826_46' class='gfield' ><label class='gfield_label' for='input_826_46'>Total</label><div class='ginput_container'><span class='ginput_total ginput_total_826'>$0.00</span><input type='hidden' name='input_46' id='input_826_46' class='gform_hidden'/></div></li><li id='field_826_108' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_826_73' class='gfield  gsection' ><h2 class='gsection_title'>Payment Information</h2></li><li id='field_826_79' class='gfield' ><label class='gfield_label' for='input_826_79'>Payment Type</label><div class='ginput_container'><select name='input_79' id='input_826_79' onchange='gf_apply_rules(826,[97,98,99,100,101]);' class='medium gfield_select' tabindex='74' ><option value='Credit Card or Debit Card' >Credit Card or Debit Card</option><option value='Money Order' >Money Order</option><option value='Cash' >Cash</option><option value='Check' >Check</option></select></div></li><li id='field_826_97' class='gfield' style='display:none;'><label class='gfield_label' for='input_826_97'>Name On Card</label><div class='ginput_container'><input name='input_97' id='input_826_97' type='text' value='' class='medium'  tabindex='75'  /></div></li><li id='field_826_98' class='gfield' style='display:none;'><label class='gfield_label' for='input_826_98'>Credit Card or Debit Card Number</label><div class='ginput_container'><input name='input_98' id='input_826_98' type='text' value='' class='medium' tabindex='76' /></div></li><li id='field_826_99' class='gfield' style='display:none;'><label class='gfield_label' for='input_826_99'>CVV</label><div class='ginput_container'><input name='input_99' id='input_826_99' type='text' value='' class='small' tabindex='77' /></div></li><li id='field_826_100' class='gfield' style='display:none;'><label class='gfield_label' for='input_826_100'>Expiration Month</label><div class='ginput_container'><select name='input_100' id='input_826_100'  class='small gfield_select' tabindex='78' ><option value='01' >January</option><option value='02' >February</option><option value='03' >March</option><option value='04' >April</option><option value='05' >May</option><option value='06' >June</option><option value='07' >July</option><option value='08' 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			<wfw:commentRss>http://www.proximotravel.com/priest-trip/fr-wesolowski-victor-r-st-rose-of-lima-catholic-church-new-lexington-oh-ilf-2012-oct-06-18/feed/</wfw:commentRss>
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		</item>
		<item>
		<title>Fr. Ezeh, Raphael, Corpus Christi Church, Chicago, IL &#8211; HLJE (2012, Nov. 08-21)</title>
		<link>http://www.proximotravel.com/priest-trip/fr-ezeh-raphael-corpus-christi-church-chicago-il-hljs-2012-nov-08-21/</link>
		<comments>http://www.proximotravel.com/priest-trip/fr-ezeh-raphael-corpus-christi-church-chicago-il-hljs-2012-nov-08-21/#comments</comments>
		<pubDate>Tue, 21 Feb 2012 19:14:52 +0000</pubDate>
		<dc:creator>abecker</dc:creator>
				<category><![CDATA[Holy Land, Jordan and Egypt - Priest Trips]]></category>
		<category><![CDATA[Priest Trips]]></category>

		<guid isPermaLink="false">http://www.proximotravel.com/?p=7979</guid>
		<description><![CDATA[Tiberia • Megiddo • Nazareth • Cana • Galilee • Jerash • Amman • Madaba • Petra • Sinai • Massada • Mount Zion • Bethlehem • Jerusalem Fr. Raphael Ezeh, MSP Corpus Christi Church, Chicago, IL Dates 2012 Nov. 08-21 $4,499 11 Days Airfare Included]]></description>
			<content:encoded><![CDATA[<h3 style="text-align: center;">Tiberia • Megiddo • Nazareth • Cana • Galilee • Jerash • Amman • Madaba • Petra • Sinai • Massada • Mount Zion • Bethlehem • Jerusalem</h3>
<hr />
<h2>Fr. Raphael Ezeh, MSP<br />
Corpus Christi Church, Chicago, IL</h2>
<h2>Dates 2012</h2>
<ul>
<li>Nov. 08-21</li>
<li>$4,499 11 Days</li>
<li>Airfare Included</li>
</ul>

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                            <h3 class='gform_title'>Holy Land, Jordan & Egypt (2012, Nov. 08-21) - Trip Registration</h3>
                            <span class='gform_description'>Please fill out the form below with your details to reserve your trip now.</span>
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                            <ul id='gform_fields_1110' class='gform_fields top_label'><li id='field_1110_50' class='gfield     gform_hidden' ><input name='input_50' id='input_1110_50' type='hidden' class='gform_hidden' value='Fr. Ezeh, Raphael, Corpus Christi Church, Chicago, IL - HLJE (2012, Nov. 08-21)' /></li><li id='field_1110_55' class='gfield     gform_hidden' ><input name='input_55' id='input_1110_55' type='hidden' class='gform_hidden' value='02/22/2012' /></li><li id='field_1110_23' class='gfield  gsection' ><h2 class='gsection_title'> Passenger #1: Name Information</h2></li><li id='field_1110_2' class='gfield' ><label class='gfield_label' for='input_1110_2'>Prefix</label><div class='ginput_container'><select name='input_2' id='input_1110_2' onchange='gf_apply_rules(1110,[97]);' class='medium gfield_select' tabindex='1' ><option value='Please select one...' >Please select one...</option><option value='Msgr.' >Msgr.</option><option value='Fr.' >Fr.</option><option value='Dr.' >Dr.</option><option value='Mr.' >Mr.</option><option value='Mrs.' >Mrs.</option><option value='Ms.' >Ms.</option></select></div></li><li id='field_1110_1' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_1'>First Name<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_1' id='input_1110_1' type='text' value='' class='medium'  tabindex='2'  /></div></li><li id='field_1110_4' class='gfield' ><label class='gfield_label' for='input_1110_4'>Middle Name or Initial (As it appears on passport)</label><div class='ginput_container'><input name='input_4' id='input_1110_4' type='text' value='' class='medium'  tabindex='3'  /></div></li><li id='field_1110_3' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_3'>Last Name<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_3' id='input_1110_3' type='text' value='' class='medium'  tabindex='4'  /></div></li><li id='field_1110_5' class='gfield' ><label class='gfield_label' for='input_1110_5'>Suffix</label><div class='ginput_container'><input name='input_5' id='input_1110_5' type='text' value='' class='medium'  tabindex='5'  /></div></li><li id='field_1110_52' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_7' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #1: Contact Information</h2></li><li id='field_1110_14' class='gfield' ><label class='gfield_label' for='input_1110_14'>Email Address</label><div class='ginput_container'><input name='input_14' id='input_1110_14' type='text' value='' class='medium'  tabindex='6'  /></div></li><li id='field_1110_15' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_15_1'>Address Information<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container' id='input_1110_15'><span class='ginput_full' id='input_1110_15_1_container'><input type='text' name='input_15.1' id='input_1110_15_1' value='' tabindex='7' /><label for='input_1110_15_1' id='input_1110_15_1_label'>Street Address</label></span><span class='ginput_full' id='input_1110_15_2_container' ><input type='text' name='input_15.2' id='input_1110_15_2' value='' tabindex='8' /><label for='input_1110_15_2' id='input_1110_15_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_1110_15_3_container'><input type='text' name='input_15.3' id='input_1110_15_3' value='' tabindex='9' /><label for='input_1110_15_3' id='input_1110_15.3_label'>City</label></span><span class='ginput_right' id='input_1110_15_4_container' ><select name='input_15.4' id='input_1110_15.4' tabindex='10'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_1110_15.4' id='input_1110_15_4_label'>State</label></span><span class='ginput_left' id='input_1110_15_5_container'><input type='text' name='input_15.5' id='input_1110_15_5' value='' tabindex='12' /><label for='input_1110_15_5' id='input_1110_15_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_1110_15_6' value='United States'/></div></li><li id='field_1110_16' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_16'>Phone (1)<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_16' id='input_1110_16' type='text' value='' class='medium' tabindex='13' /></div></li><li id='field_1110_17' class='gfield' ><label class='gfield_label' for='input_1110_17'>Phone (2)</label><div class='ginput_container'><input name='input_17' id='input_1110_17' type='text' value='' class='medium' tabindex='14' /></div></li><li id='field_1110_63' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_62' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #1: Passport Information</h2></li><li id='field_1110_47' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_47'>Do you have a passport?<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_47' id='input_1110_47' onchange='gf_apply_rules(1110,[64,68]);' class='medium gfield_select' tabindex='15' ><option value='' selected='selected'>Please select...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_1110_18' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_18'>Date of Birth<span class='gfield_required'>*</span></label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1110_18'><input type='text' maxlength='2' name='input_18[]' id='input_1110_18.1' value='' tabindex='16' /><label for='input_1110_18.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1110_18'><input type='text' maxlength='2' name='input_18[]' id='input_1110_18.2' value='' tabindex='17' /><label for='input_1110_18.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1110_18'><input type='text' maxlength='4' name='input_18[]' id='input_1110_18.3' value='' tabindex='18' /><label for='input_1110_18.3'>YYYY</label></div></div></li><li id='field_1110_20' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_20'>Gender<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_20' id='input_1110_20'  class='medium gfield_select' tabindex='19' ><option value='' selected='selected'>Select one...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_1110_64' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_64'>Passport Number</label><div class='ginput_container'><input name='input_64' id='input_1110_64' type='text' value='' class='small'  tabindex='20'  /></div></li><li id='field_1110_68' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_68'>Country of Issuance</label><div class='ginput_container'><select name='input_68' id='input_1110_68'  class='medium gfield_select' tabindex='21' ><option value='Select one...' >Select one...</option><option value='United States of America' >United States of America</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_1110_149' class='gfield' ><label class='gfield_label' for='input_1110_149'>Date of Expiration</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1110_149'><input type='text' maxlength='2' name='input_149[]' id='input_1110_149.1' value='' tabindex='22' /><label for='input_1110_149.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1110_149'><input type='text' maxlength='2' name='input_149[]' id='input_1110_149.2' value='' tabindex='23' /><label for='input_1110_149.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1110_149'><input type='text' maxlength='4' name='input_149[]' id='input_1110_149.3' value='' tabindex='24' /><label for='input_1110_149.3'>YYYY</label></div></div></li><li id='field_1110_70' class='gfield' ><label class='gfield_label' for='input_1110_70'>Upload Passport Image</label><div class='ginput_container'><input name='input_70' id='input_1110_70' type='file' value='' size='20' class='medium' tabindex='25' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_1110_54' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_24' class='gfield  gsection' ><h2 class='gsection_title'>Passenger  #1: Emergency Contact Information</h2></li><li id='field_1110_26' class='gfield' ><label class='gfield_label' for='input_1110_26.3'>Name</label><div class='ginput_complex ginput_container' id='input_1110_26'><span id='input_1110_26_3_container' class='ginput_left'><input type='text' name='input_26.3' id='input_1110_26_3' value='' tabindex='26' /><label for='input_1110_26_3'>First</label></span><span id='input_1110_26_6_container' class='ginput_right'><input type='text' name='input_26.6' id='input_1110_26_6' value='' tabindex='27' /><label for='input_1110_26_6'>Last</label></span></div></li><li id='field_1110_27' class='gfield' ><label class='gfield_label' for='input_1110_27'>Phone (1)</label><div class='ginput_container'><input name='input_27' id='input_1110_27' type='text' value='' class='medium' tabindex='28' /></div></li><li id='field_1110_28' class='gfield' ><label class='gfield_label' for='input_1110_28'>Phone (2)</label><div class='ginput_container'><input name='input_28' id='input_1110_28' type='text' value='' class='medium' tabindex='29' /></div></li><li id='field_1110_29' class='gfield' ><label class='gfield_label' for='input_1110_29'>Relationship</label><div class='ginput_container'><input name='input_29' id='input_1110_29' type='text' value='' class='medium'  tabindex='30'  /></div></li><li id='field_1110_49' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_21' class='gfield  gsection' ><h2 class='gsection_title'>Special Trip Details and Requests</h2></li><li id='field_1110_60' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_60'>Departure Airport<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_60' id='input_1110_60' type='text' value='' class='medium'  tabindex='31'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_1110_85' class='gfield' ><label class='gfield_label' for='input_1110_85'>Seating Preference</label><div class='ginput_container'><select name='input_85' id='input_1110_85'  class='medium gfield_select' tabindex='32' ><option value='Select below...' >Select below...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_1110_22' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1110_22'><li class='gchoice_22_1'><input name='input_22.1' type='checkbox'  value='*Special dietary concerns / requests'  id='choice_22_1' tabindex='33'  /><label for='choice_22_1'>*Special dietary concerns / requests</label></li><li class='gchoice_22_2'><input name='input_22.2' type='checkbox'  value='Wheelchair requirement'  id='choice_22_2' tabindex='34'  /><label for='choice_22_2'>Wheelchair requirement</label></li><li class='gchoice_22_3'><input name='input_22.3' type='checkbox'  value='Others (please contact me)'  id='choice_22_3' tabindex='35'  /><label for='choice_22_3'>Others (please contact me)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_1110_145' class='gfield' ><label class='gfield_label' for='input_1110_145'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_145' id='input_1110_145' type='text' value='' class='medium'  tabindex='36'  /></div></li><li id='field_1110_25' class='gfield' ><label class='gfield_label' for='input_1110_25'>I would like to travel and/or room with these people:</label><div class='ginput_container'><textarea name='input_25' id='input_1110_25' class='textarea small' tabindex='37'  rows='10' cols='50'></textarea></div></li><li id='field_1110_126' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_150' class='gfield' ><label class='gfield_label'>Registering an additional passenger?</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1110_150'><li class='gchoice_150_1'><input name='input_150.1' type='checkbox' onclick='gf_apply_rules(1110,[129,129,121,139,121,139,128,128,123,122,124,125,140,123,122,124,125,140,130,130,131,132,133,146,147,148,134,141,131,132,133,146,147,148,134,141,135,135,143,136,137,138,142,143,136,137,138,142,30,30,31,32,33,34,48,31,32,33,34,48]);' value='Yes'  id='choice_150_1' tabindex='38'  /><label for='choice_150_1'>Yes</label></li></ul></div></li><li id='field_1110_127' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_129' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Name Information</h2></li><li id='field_1110_121' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_121.3'>Name as it appears on Passport</label><div class='ginput_container'><input name='input_121' id='input_1110_121' type='text' value='' class='medium' tabindex='39' /></div></li><li id='field_1110_139' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_128' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Contact Information (If different from Passenger #1)</h2></li><li id='field_1110_123' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_123'>Passenger #2: Email Address</label><div class='ginput_container'><input name='input_123' id='input_1110_123' type='text' value='' class='medium'  tabindex='40'  /></div></li><li id='field_1110_122' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_122_1'>Passenger #2: Address</label><div class='ginput_complex ginput_container' id='input_1110_122'><span class='ginput_full' id='input_1110_122_1_container'><input type='text' name='input_122.1' id='input_1110_122_1' value='' tabindex='41' /><label for='input_1110_122_1' id='input_1110_122_1_label'>Street Address</label></span><span class='ginput_full' id='input_1110_122_2_container' ><input type='text' name='input_122.2' id='input_1110_122_2' value='' tabindex='42' /><label for='input_1110_122_2' id='input_1110_122_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_1110_122_3_container'><input type='text' name='input_122.3' id='input_1110_122_3' value='' tabindex='43' /><label for='input_1110_122_3' id='input_1110_122.3_label'>City</label></span><span class='ginput_right' id='input_1110_122_4_container' ><select name='input_122.4' id='input_1110_122.4' tabindex='44'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_1110_122.4' id='input_1110_122_4_label'>State</label></span><span class='ginput_left' id='input_1110_122_5_container'><input type='text' name='input_122.5' id='input_1110_122_5' value='' tabindex='46' /><label for='input_1110_122_5' id='input_1110_122_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_122.6' id='input_1110_122_6' value='United States'/></div></li><li id='field_1110_124' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_124'>Passenger #2: Phone (1)</label><div class='ginput_container'><input name='input_124' id='input_1110_124' type='text' value='' class='medium' tabindex='47' /></div></li><li id='field_1110_125' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_125'>Passenger #2: Phone (2)</label><div class='ginput_container'><input name='input_125' id='input_1110_125' type='text' value='' class='medium' tabindex='48' /></div></li><li id='field_1110_140' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_130' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Passport Information</h2></li><li id='field_1110_131' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_131'>Do you have a Passport?</label><div class='ginput_container'><select name='input_131' id='input_1110_131'  class='small gfield_select' tabindex='49' ><option value='Please select ...' >Please select ...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_1110_132' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_132'>Date of Birth</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1110_132'><input type='text' maxlength='2' name='input_132[]' id='input_1110_132.1' value='' tabindex='50' /><label for='input_1110_132.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1110_132'><input type='text' maxlength='2' name='input_132[]' id='input_1110_132.2' value='' tabindex='51' /><label for='input_1110_132.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1110_132'><input type='text' maxlength='4' name='input_132[]' id='input_1110_132.3' value='' tabindex='52' /><label for='input_1110_132.3'>YYYY</label></div></div></li><li id='field_1110_133' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_133'>Gender</label><div class='ginput_container'><select name='input_133' id='input_1110_133'  class='small gfield_select' tabindex='53' ><option value='Please select ...' >Please select ...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_1110_146' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_146'>Passport Number</label><div class='ginput_container'><input name='input_146' id='input_1110_146' type='text' value='' class='medium'  tabindex='54'  /></div></li><li id='field_1110_147' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_147'>Country of Issuance:</label><div class='ginput_container'><select name='input_147' id='input_1110_147'  class='medium gfield_select' tabindex='55' ><option value='Please select...' >Please select...</option><option value='United States of American' >United States of American</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_1110_148' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_148'>Date of Expiration</label><div class='ginput_container'><input name='input_148' id='input_1110_148' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='56' /> </div><input type='hidden' id='gforms_calendar_icon_input_1110_148' class='gform_hidden' value='http://www.proximotravel.com/website/wp-content/plugins/gravityforms/images/calendar.png'/></li><li id='field_1110_134' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_134'>Upload Passport Image</label><div class='ginput_container'><input name='input_134' id='input_1110_134' type='file' value='' size='20' class='medium' tabindex='57' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_1110_141' class='gfield      gfield_html gfield_html_formatted' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_135' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Special Trip Details &amp; Requests</h2></li><li id='field_1110_143' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_143'>Passenger #2: Departure Airport</label><div class='ginput_container'><input name='input_143' id='input_1110_143' type='text' value='' class='medium'  tabindex='58'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_1110_136' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_136'>Seat Preferences</label><div class='ginput_container'><select name='input_136' id='input_1110_136'  class='medium gfield_select' tabindex='59' ><option value='Select below ...' >Select below ...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_1110_137' class='gfield' style='display:none;'><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1110_137'><li class='gchoice_137_1'><input name='input_137.1' type='checkbox'  value='*Special dietary concernes/requests'  id='choice_137_1' tabindex='60'  /><label for='choice_137_1'>*Special dietary concernes/requests</label></li><li class='gchoice_137_2'><input name='input_137.2' type='checkbox'  value='Wheelchair requirements'  id='choice_137_2' tabindex='61'  /><label for='choice_137_2'>Wheelchair requirements</label></li><li class='gchoice_137_3'><input name='input_137.3' type='checkbox'  value='Others (Please contact me.)'  id='choice_137_3' tabindex='62'  /><label for='choice_137_3'>Others (Please contact me.)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_1110_138' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_138'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_138' id='input_1110_138' type='text' value='' class='medium'  tabindex='63'  /></div></li><li id='field_1110_142' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_30' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Emergency Contact Information </h2></li><li id='field_1110_31' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_31.3'>Name</label><div class='ginput_complex ginput_container' id='input_1110_31'><span id='input_1110_31_3_container' class='ginput_left'><input type='text' name='input_31.3' id='input_1110_31_3' value='' tabindex='64' /><label for='input_1110_31_3'>First</label></span><span id='input_1110_31_6_container' class='ginput_right'><input type='text' name='input_31.6' id='input_1110_31_6' value='' tabindex='65' /><label for='input_1110_31_6'>Last</label></span></div></li><li id='field_1110_32' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_32'>Phone (1)</label><div class='ginput_container'><input name='input_32' id='input_1110_32' type='text' value='' class='medium' tabindex='66' /></div></li><li id='field_1110_33' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_33'>Phone (2)</label><div class='ginput_container'><input name='input_33' id='input_1110_33' type='text' value='' class='medium' tabindex='67' /></div></li><li id='field_1110_34' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_34'>Relationship</label><div class='ginput_container'><input name='input_34' id='input_1110_34' type='text' value='' class='medium'  tabindex='68'  /></div></li><li id='field_1110_48' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_38' class='gfield  gsection' ><h2 class='gsection_title'>Purchasing Options</h2><div class='gsection_description'>In order to register and save your place on the trip, a $500 non-refundable deposit is required  Payment in full must be received at 857 West Boylston St. Worcester, MA 01606, 90 days prior to trip date.</div></li><li id='field_1110_119' class='gfield           gfield_price gfield_price_1110_119 gfield_product_1110_119' ><label class='gfield_label' for='input_1110_119'>*Total Trip Price</label><div class='ginput_container'><input type='hidden' name='input_119.1' value='*Total Trip Price' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1110_119'>$4,618.97</span><input type='hidden' name='input_119.2' id='ginput_base_price_1110_119' class='gform_hidden' value='$4,618.97'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_119.3' value='' id='ginput_quantity_1110_119' class='ginput_quantity' size='10' tabindex='69'/></div><div class='gfield_description'>* There is NO 3% credit/debit card surcharge for the initial deposit or travel cancellation protection. If payment is made in full, the 3% credit/debit card surcharge applies ONLY to the cost of the trip less the deposit and travel cancellation protection (if purchased).
For this trip, the 3% credit/debit surcharge is $119.97.
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<hr /></li><li id='field_1110_111' class='gfield  gsection' ><h2 class='gsection_title'>No Liability Agreement</h2></li><li id='field_1110_95' class='gfield               gfield_contains_required' ><label class='gfield_label'>Checking this box means that I agree that no liability is assumed by Antoine Nachef, Proximo Travel, LLC or employees of Proximo Travel, LLC for injuries to person(s) or damage to property while on any trip hosted by Proximo Travel, LLC.<span class='gfield_required'>*</span></label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1110_95'><li class='gchoice_95_1'><input name='input_95.1' type='checkbox'  value='I Agree'  id='choice_95_1' tabindex='89'  /><label for='choice_95_1'>I Agree</label></li></ul></div></li><li id='field_1110_102' class='gfield     gform_hidden' ><input name='input_102' id='input_1110_102' type='hidden' class='gform_hidden' value='' /></li>
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		<item>
		<title>Holy Land, Jordan and Egypt (2012, Nov. 08-21)</title>
		<link>http://www.proximotravel.com/general-trips/holy-land-jordan-and-sinai-2012-nov-08-21/</link>
		<comments>http://www.proximotravel.com/general-trips/holy-land-jordan-and-sinai-2012-nov-08-21/#comments</comments>
		<pubDate>Tue, 21 Feb 2012 18:10:36 +0000</pubDate>
		<dc:creator>abecker</dc:creator>
				<category><![CDATA[General Trips]]></category>
		<category><![CDATA[Holy Land, Jordan and Egypt]]></category>

		<guid isPermaLink="false">http://www.proximotravel.com/?p=7958</guid>
		<description><![CDATA[Tiberia • Megiddo • Nazareth • Cana • Galilee • Jerash • Amman • Madaba • Petra • Sinai • Massada • Mount Zion • Bethlehem • Jerusalem &#160;]]></description>
			<content:encoded><![CDATA[<h3 style="text-align: center;">Tiberia • Megiddo • Nazareth • Cana • Galilee • Jerash • Amman • Madaba • Petra • Sinai • Massada • Mount Zion • Bethlehem • Jerusalem</h3>
<hr />

                <div class='gform_wrapper' id='gform_wrapper_1110' style='display:none'><form method='post' enctype='multipart/form-data'  id='gform_1110'  action='/feed/'>
                        <div class='gform_heading'>
                            <h3 class='gform_title'>Holy Land, Jordan & Egypt (2012, Nov. 08-21) - Trip Registration</h3>
                            <span class='gform_description'>Please fill out the form below with your details to reserve your trip now.</span>
                        </div>
                        <div class='gform_body'>
                            <ul id='gform_fields_1110' class='gform_fields top_label'><li id='field_1110_50' class='gfield     gform_hidden' ><input name='input_50' id='input_1110_50' type='hidden' class='gform_hidden' value='Holy Land, Jordan and Egypt (2012, Nov. 08-21)' /></li><li id='field_1110_55' class='gfield     gform_hidden' ><input name='input_55' id='input_1110_55' type='hidden' class='gform_hidden' value='02/22/2012' /></li><li id='field_1110_23' class='gfield  gsection' ><h2 class='gsection_title'> Passenger #1: Name Information</h2></li><li id='field_1110_2' class='gfield' ><label class='gfield_label' for='input_1110_2'>Prefix</label><div class='ginput_container'><select name='input_2' id='input_1110_2' onchange='gf_apply_rules(1110,[97]);' class='medium gfield_select' tabindex='1' ><option value='Please select one...' >Please select one...</option><option value='Msgr.' >Msgr.</option><option value='Fr.' >Fr.</option><option value='Dr.' >Dr.</option><option value='Mr.' >Mr.</option><option value='Mrs.' >Mrs.</option><option value='Ms.' >Ms.</option></select></div></li><li id='field_1110_1' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_1'>First Name<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_1' id='input_1110_1' type='text' value='' class='medium'  tabindex='2'  /></div></li><li id='field_1110_4' class='gfield' ><label class='gfield_label' for='input_1110_4'>Middle Name or Initial (As it appears on passport)</label><div class='ginput_container'><input name='input_4' id='input_1110_4' type='text' value='' class='medium'  tabindex='3'  /></div></li><li id='field_1110_3' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_3'>Last Name<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_3' id='input_1110_3' type='text' value='' class='medium'  tabindex='4'  /></div></li><li id='field_1110_5' class='gfield' ><label class='gfield_label' for='input_1110_5'>Suffix</label><div class='ginput_container'><input name='input_5' id='input_1110_5' type='text' value='' class='medium'  tabindex='5'  /></div></li><li id='field_1110_52' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_7' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #1: Contact Information</h2></li><li id='field_1110_14' class='gfield' ><label class='gfield_label' for='input_1110_14'>Email Address</label><div class='ginput_container'><input name='input_14' id='input_1110_14' type='text' value='' class='medium'  tabindex='6'  /></div></li><li id='field_1110_15' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_15_1'>Address Information<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container' id='input_1110_15'><span class='ginput_full' id='input_1110_15_1_container'><input type='text' name='input_15.1' id='input_1110_15_1' value='' tabindex='7' /><label for='input_1110_15_1' id='input_1110_15_1_label'>Street Address</label></span><span class='ginput_full' id='input_1110_15_2_container' ><input type='text' name='input_15.2' id='input_1110_15_2' value='' tabindex='8' /><label for='input_1110_15_2' id='input_1110_15_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_1110_15_3_container'><input type='text' name='input_15.3' id='input_1110_15_3' value='' tabindex='9' /><label for='input_1110_15_3' id='input_1110_15.3_label'>City</label></span><span class='ginput_right' id='input_1110_15_4_container' ><select name='input_15.4' id='input_1110_15.4' tabindex='10'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_1110_15.4' id='input_1110_15_4_label'>State</label></span><span class='ginput_left' id='input_1110_15_5_container'><input type='text' name='input_15.5' id='input_1110_15_5' value='' tabindex='12' /><label for='input_1110_15_5' id='input_1110_15_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_15.6' id='input_1110_15_6' value='United States'/></div></li><li id='field_1110_16' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_16'>Phone (1)<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_16' id='input_1110_16' type='text' value='' class='medium' tabindex='13' /></div></li><li id='field_1110_17' class='gfield' ><label class='gfield_label' for='input_1110_17'>Phone (2)</label><div class='ginput_container'><input name='input_17' id='input_1110_17' type='text' value='' class='medium' tabindex='14' /></div></li><li id='field_1110_63' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_62' class='gfield  gsection' ><h2 class='gsection_title'>Passenger #1: Passport Information</h2></li><li id='field_1110_47' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_47'>Do you have a passport?<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_47' id='input_1110_47' onchange='gf_apply_rules(1110,[64,68]);' class='medium gfield_select' tabindex='15' ><option value='' selected='selected'>Please select...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_1110_18' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_18'>Date of Birth<span class='gfield_required'>*</span></label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1110_18'><input type='text' maxlength='2' name='input_18[]' id='input_1110_18.1' value='' tabindex='16' /><label for='input_1110_18.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1110_18'><input type='text' maxlength='2' name='input_18[]' id='input_1110_18.2' value='' tabindex='17' /><label for='input_1110_18.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1110_18'><input type='text' maxlength='4' name='input_18[]' id='input_1110_18.3' value='' tabindex='18' /><label for='input_1110_18.3'>YYYY</label></div></div></li><li id='field_1110_20' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_20'>Gender<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_20' id='input_1110_20'  class='medium gfield_select' tabindex='19' ><option value='' selected='selected'>Select one...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_1110_64' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_64'>Passport Number</label><div class='ginput_container'><input name='input_64' id='input_1110_64' type='text' value='' class='small'  tabindex='20'  /></div></li><li id='field_1110_68' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_68'>Country of Issuance</label><div class='ginput_container'><select name='input_68' id='input_1110_68'  class='medium gfield_select' tabindex='21' ><option value='Select one...' >Select one...</option><option value='United States of America' >United States of America</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_1110_149' class='gfield' ><label class='gfield_label' for='input_1110_149'>Date of Expiration</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1110_149'><input type='text' maxlength='2' name='input_149[]' id='input_1110_149.1' value='' tabindex='22' /><label for='input_1110_149.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1110_149'><input type='text' maxlength='2' name='input_149[]' id='input_1110_149.2' value='' tabindex='23' /><label for='input_1110_149.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1110_149'><input type='text' maxlength='4' name='input_149[]' id='input_1110_149.3' value='' tabindex='24' /><label for='input_1110_149.3'>YYYY</label></div></div></li><li id='field_1110_70' class='gfield' ><label class='gfield_label' for='input_1110_70'>Upload Passport Image</label><div class='ginput_container'><input name='input_70' id='input_1110_70' type='file' value='' size='20' class='medium' tabindex='25' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_1110_54' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_24' class='gfield  gsection' ><h2 class='gsection_title'>Passenger  #1: Emergency Contact Information</h2></li><li id='field_1110_26' class='gfield' ><label class='gfield_label' for='input_1110_26.3'>Name</label><div class='ginput_complex ginput_container' id='input_1110_26'><span id='input_1110_26_3_container' class='ginput_left'><input type='text' name='input_26.3' id='input_1110_26_3' value='' tabindex='26' /><label for='input_1110_26_3'>First</label></span><span id='input_1110_26_6_container' class='ginput_right'><input type='text' name='input_26.6' id='input_1110_26_6' value='' tabindex='27' /><label for='input_1110_26_6'>Last</label></span></div></li><li id='field_1110_27' class='gfield' ><label class='gfield_label' for='input_1110_27'>Phone (1)</label><div class='ginput_container'><input name='input_27' id='input_1110_27' type='text' value='' class='medium' tabindex='28' /></div></li><li id='field_1110_28' class='gfield' ><label class='gfield_label' for='input_1110_28'>Phone (2)</label><div class='ginput_container'><input name='input_28' id='input_1110_28' type='text' value='' class='medium' tabindex='29' /></div></li><li id='field_1110_29' class='gfield' ><label class='gfield_label' for='input_1110_29'>Relationship</label><div class='ginput_container'><input name='input_29' id='input_1110_29' type='text' value='' class='medium'  tabindex='30'  /></div></li><li id='field_1110_49' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_21' class='gfield  gsection' ><h2 class='gsection_title'>Special Trip Details and Requests</h2></li><li id='field_1110_60' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1110_60'>Departure Airport<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_60' id='input_1110_60' type='text' value='' class='medium'  tabindex='31'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_1110_85' class='gfield' ><label class='gfield_label' for='input_1110_85'>Seating Preference</label><div class='ginput_container'><select name='input_85' id='input_1110_85'  class='medium gfield_select' tabindex='32' ><option value='Select below...' >Select below...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_1110_22' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1110_22'><li class='gchoice_22_1'><input name='input_22.1' type='checkbox'  value='*Special dietary concerns / requests'  id='choice_22_1' tabindex='33'  /><label for='choice_22_1'>*Special dietary concerns / requests</label></li><li class='gchoice_22_2'><input name='input_22.2' type='checkbox'  value='Wheelchair requirement'  id='choice_22_2' tabindex='34'  /><label for='choice_22_2'>Wheelchair requirement</label></li><li class='gchoice_22_3'><input name='input_22.3' type='checkbox'  value='Others (please contact me)'  id='choice_22_3' tabindex='35'  /><label for='choice_22_3'>Others (please contact me)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_1110_145' class='gfield' ><label class='gfield_label' for='input_1110_145'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_145' id='input_1110_145' type='text' value='' class='medium'  tabindex='36'  /></div></li><li id='field_1110_25' class='gfield' ><label class='gfield_label' for='input_1110_25'>I would like to travel and/or room with these people:</label><div class='ginput_container'><textarea name='input_25' id='input_1110_25' class='textarea small' tabindex='37'  rows='10' cols='50'></textarea></div></li><li id='field_1110_126' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_150' class='gfield' ><label class='gfield_label'>Registering an additional passenger?</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1110_150'><li class='gchoice_150_1'><input name='input_150.1' type='checkbox' onclick='gf_apply_rules(1110,[129,129,121,139,121,139,128,128,123,122,124,125,140,123,122,124,125,140,130,130,131,132,133,146,147,148,134,141,131,132,133,146,147,148,134,141,135,135,143,136,137,138,142,143,136,137,138,142,30,30,31,32,33,34,48,31,32,33,34,48]);' value='Yes'  id='choice_150_1' tabindex='38'  /><label for='choice_150_1'>Yes</label></li></ul></div></li><li id='field_1110_127' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_129' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Name Information</h2></li><li id='field_1110_121' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_121.3'>Name as it appears on Passport</label><div class='ginput_container'><input name='input_121' id='input_1110_121' type='text' value='' class='medium' tabindex='39' /></div></li><li id='field_1110_139' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_128' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Contact Information (If different from Passenger #1)</h2></li><li id='field_1110_123' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_123'>Passenger #2: Email Address</label><div class='ginput_container'><input name='input_123' id='input_1110_123' type='text' value='' class='medium'  tabindex='40'  /></div></li><li id='field_1110_122' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_122_1'>Passenger #2: Address</label><div class='ginput_complex ginput_container' id='input_1110_122'><span class='ginput_full' id='input_1110_122_1_container'><input type='text' name='input_122.1' id='input_1110_122_1' value='' tabindex='41' /><label for='input_1110_122_1' id='input_1110_122_1_label'>Street Address</label></span><span class='ginput_full' id='input_1110_122_2_container' ><input type='text' name='input_122.2' id='input_1110_122_2' value='' tabindex='42' /><label for='input_1110_122_2' id='input_1110_122_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_1110_122_3_container'><input type='text' name='input_122.3' id='input_1110_122_3' value='' tabindex='43' /><label for='input_1110_122_3' id='input_1110_122.3_label'>City</label></span><span class='ginput_right' id='input_1110_122_4_container' ><select name='input_122.4' id='input_1110_122.4' tabindex='44'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_1110_122.4' id='input_1110_122_4_label'>State</label></span><span class='ginput_left' id='input_1110_122_5_container'><input type='text' name='input_122.5' id='input_1110_122_5' value='' tabindex='46' /><label for='input_1110_122_5' id='input_1110_122_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_122.6' id='input_1110_122_6' value='United States'/></div></li><li id='field_1110_124' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_124'>Passenger #2: Phone (1)</label><div class='ginput_container'><input name='input_124' id='input_1110_124' type='text' value='' class='medium' tabindex='47' /></div></li><li id='field_1110_125' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_125'>Passenger #2: Phone (2)</label><div class='ginput_container'><input name='input_125' id='input_1110_125' type='text' value='' class='medium' tabindex='48' /></div></li><li id='field_1110_140' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_130' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Passport Information</h2></li><li id='field_1110_131' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_131'>Do you have a Passport?</label><div class='ginput_container'><select name='input_131' id='input_1110_131'  class='small gfield_select' tabindex='49' ><option value='Please select ...' >Please select ...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_1110_132' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_132'>Date of Birth</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1110_132'><input type='text' maxlength='2' name='input_132[]' id='input_1110_132.1' value='' tabindex='50' /><label for='input_1110_132.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1110_132'><input type='text' maxlength='2' name='input_132[]' id='input_1110_132.2' value='' tabindex='51' /><label for='input_1110_132.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1110_132'><input type='text' maxlength='4' name='input_132[]' id='input_1110_132.3' value='' tabindex='52' /><label for='input_1110_132.3'>YYYY</label></div></div></li><li id='field_1110_133' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_133'>Gender</label><div class='ginput_container'><select name='input_133' id='input_1110_133'  class='small gfield_select' tabindex='53' ><option value='Please select ...' >Please select ...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_1110_146' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_146'>Passport Number</label><div class='ginput_container'><input name='input_146' id='input_1110_146' type='text' value='' class='medium'  tabindex='54'  /></div></li><li id='field_1110_147' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_147'>Country of Issuance:</label><div class='ginput_container'><select name='input_147' id='input_1110_147'  class='medium gfield_select' tabindex='55' ><option value='Please select...' >Please select...</option><option value='United States of American' >United States of American</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_1110_148' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_148'>Date of Expiration</label><div class='ginput_container'><input name='input_148' id='input_1110_148' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='56' /> </div><input type='hidden' id='gforms_calendar_icon_input_1110_148' class='gform_hidden' value='http://www.proximotravel.com/website/wp-content/plugins/gravityforms/images/calendar.png'/></li><li id='field_1110_134' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_134'>Upload Passport Image</label><div class='ginput_container'><input name='input_134' id='input_1110_134' type='file' value='' size='20' class='medium' tabindex='57' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_1110_141' class='gfield      gfield_html gfield_html_formatted' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_135' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Special Trip Details &amp; Requests</h2></li><li id='field_1110_143' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_143'>Passenger #2: Departure Airport</label><div class='ginput_container'><input name='input_143' id='input_1110_143' type='text' value='' class='medium'  tabindex='58'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_1110_136' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_136'>Seat Preferences</label><div class='ginput_container'><select name='input_136' id='input_1110_136'  class='medium gfield_select' tabindex='59' ><option value='Select below ...' >Select below ...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_1110_137' class='gfield' style='display:none;'><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1110_137'><li class='gchoice_137_1'><input name='input_137.1' type='checkbox'  value='*Special dietary concernes/requests'  id='choice_137_1' tabindex='60'  /><label for='choice_137_1'>*Special dietary concernes/requests</label></li><li class='gchoice_137_2'><input name='input_137.2' type='checkbox'  value='Wheelchair requirements'  id='choice_137_2' tabindex='61'  /><label for='choice_137_2'>Wheelchair requirements</label></li><li class='gchoice_137_3'><input name='input_137.3' type='checkbox'  value='Others (Please contact me.)'  id='choice_137_3' tabindex='62'  /><label for='choice_137_3'>Others (Please contact me.)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_1110_138' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_138'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_138' id='input_1110_138' type='text' value='' class='medium'  tabindex='63'  /></div></li><li id='field_1110_142' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_30' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Emergency Contact Information </h2></li><li id='field_1110_31' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_31.3'>Name</label><div class='ginput_complex ginput_container' id='input_1110_31'><span id='input_1110_31_3_container' class='ginput_left'><input type='text' name='input_31.3' id='input_1110_31_3' value='' tabindex='64' /><label for='input_1110_31_3'>First</label></span><span id='input_1110_31_6_container' class='ginput_right'><input type='text' name='input_31.6' id='input_1110_31_6' value='' tabindex='65' /><label for='input_1110_31_6'>Last</label></span></div></li><li id='field_1110_32' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_32'>Phone (1)</label><div class='ginput_container'><input name='input_32' id='input_1110_32' type='text' value='' class='medium' tabindex='66' /></div></li><li id='field_1110_33' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_33'>Phone (2)</label><div class='ginput_container'><input name='input_33' id='input_1110_33' type='text' value='' class='medium' tabindex='67' /></div></li><li id='field_1110_34' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_34'>Relationship</label><div class='ginput_container'><input name='input_34' id='input_1110_34' type='text' value='' class='medium'  tabindex='68'  /></div></li><li id='field_1110_48' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1110_38' class='gfield  gsection' ><h2 class='gsection_title'>Purchasing Options</h2><div class='gsection_description'>In order to register and save your place on the trip, a $500 non-refundable deposit is required  Payment in full must be received at 857 West Boylston St. Worcester, MA 01606, 90 days prior to trip date.</div></li><li id='field_1110_119' class='gfield           gfield_price gfield_price_1110_119 gfield_product_1110_119' ><label class='gfield_label' for='input_1110_119'>*Total Trip Price</label><div class='ginput_container'><input type='hidden' name='input_119.1' value='*Total Trip Price' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1110_119'>$4,618.97</span><input type='hidden' name='input_119.2' id='ginput_base_price_1110_119' class='gform_hidden' value='$4,618.97'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_119.3' value='' id='ginput_quantity_1110_119' class='ginput_quantity' size='10' tabindex='69'/></div><div class='gfield_description'>* There is NO 3% credit/debit card surcharge for the initial deposit or travel cancellation protection. If payment is made in full, the 3% credit/debit card surcharge applies ONLY to the cost of the trip less the deposit and travel cancellation protection (if purchased).
For this trip, the 3% credit/debit surcharge is $119.97.
</div></li><li id='field_1110_116' class='gfield           gfield_price gfield_price_1110_116 gfield_product_1110_116' ><label class='gfield_label' for='input_1110_116'>Deposit</label><div class='ginput_container'><input type='hidden' name='input_116.1' value='Deposit' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1110_116'>$500.00</span><input type='hidden' name='input_116.2' id='ginput_base_price_1110_116' class='gform_hidden' value='$500.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_116.3' value='' id='ginput_quantity_1110_116' class='ginput_quantity' size='10' tabindex='70'/></div></li><li id='field_1110_117' class='gfield           gfield_price gfield_price_1110_117 gfield_product_1110_117' ><label class='gfield_label' for='input_1110_117'>Travel Cancellation Protection</label><div class='ginput_container'><input type='hidden' name='input_117.1' value='Travel Cancellation Protection' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1110_117'>$200.00</span><input type='hidden' name='input_117.2' id='ginput_base_price_1110_117' class='gform_hidden' value='$200.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_117.3' value='' id='ginput_quantity_1110_117' class='ginput_quantity' size='10' tabindex='71'/></div></li><li id='field_1110_115' class='gfield           gfield_price gfield_price_1110_115 gfield_product_1110_115' ><label class='gfield_label' for='input_1110_115'>Single Supplement</label><div class='ginput_container'><input type='hidden' name='input_115.1' value='Single Supplement' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1110_115'>$700.00</span><input type='hidden' name='input_115.2' id='ginput_base_price_1110_115' class='gform_hidden' value='$700.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_115.3' value='' id='ginput_quantity_1110_115' class='ginput_quantity' size='10' tabindex='72'/></div><div class='gfield_description'>If you are traveling by yourself and prefer your own room.</div></li><li id='field_1110_96' class='gfield            gfield_price gfield_price_1110_96 gfield_donation_1110_96' ><label class='gfield_label' for='input_1110_96'>Custom Amount</label><div class='ginput_container'><input name='input_96' id='input_1110_96' type='text' value='' class='medium' tabindex='73' /></div></li><li id='field_1110_46' class='gfield' ><label class='gfield_label' for='input_1110_46'>Total</label><div class='ginput_container'><span class='ginput_total ginput_total_1110'>$0.00</span><input type='hidden' name='input_46' id='input_1110_46' class='gform_hidden'/></div></li><li id='field_1110_108' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_73' class='gfield  gsection' ><h2 class='gsection_title'>Payment Information</h2></li><li id='field_1110_79' class='gfield' ><label class='gfield_label' for='input_1110_79'>Payment Type</label><div class='ginput_container'><select name='input_79' id='input_1110_79' onchange='gf_apply_rules(1110,[97,98,99,100,101]);' class='medium gfield_select' tabindex='74' ><option value='Credit Card or Debit Credit' >Credit Card or Debit Credit</option><option value='Money Order' >Money Order</option><option value='Cash' >Cash</option><option value='Check' >Check</option></select></div></li><li id='field_1110_97' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_97'>Name On Card</label><div class='ginput_container'><input name='input_97' id='input_1110_97' type='text' value='' class='medium'  tabindex='75'  /></div></li><li id='field_1110_98' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_98'>Credit Card or Debit Card Number</label><div class='ginput_container'><input name='input_98' id='input_1110_98' type='text' value='' class='medium' tabindex='76' /></div></li><li id='field_1110_99' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_99'>CVV</label><div class='ginput_container'><input name='input_99' id='input_1110_99' type='text' value='' class='small' tabindex='77' /></div></li><li id='field_1110_100' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_100'>Expiration Month</label><div class='ginput_container'><select name='input_100' id='input_1110_100'  class='small gfield_select' tabindex='78' ><option value='01' >January</option><option value='02' >February</option><option value='03' >March</option><option value='04' >April</option><option value='05' >May</option><option value='06' >June</option><option value='07' >July</option><option value='08' >August</option><option value='09' >September</option><option value='10' >October</option><option value='11' >November</option><option value='12' >December</option></select></div></li><li id='field_1110_101' class='gfield' style='display:none;'><label class='gfield_label' for='input_1110_101'>Expiration Year</label><div class='ginput_container'><select name='input_101' id='input_1110_101'  class='small gfield_select' tabindex='79' ><option value='12' >2012</option><option value='13' >2013</option><option value='14' >2014</option><option value='15' >2015</option><option value='16' >2016</option><option value='17' >2017</option><option value='18' >2018</option><option value='19' >2019</option><option value='20' >2020</option><option value='21' >2021</option><option value='22' >2022</option><option value='23' >2023</option><option value='24' >2024</option><option value='25' >2025</option></select></div></li><li id='field_1110_103' class='gfield' ><label class='gfield_label'>Check if Billing Address and Mailing Address are the same.</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1110_103'><li class='gchoice_103_1'><input name='input_103.1' type='checkbox' onclick='gf_apply_rules(1110,[77]);' value='Same'  id='choice_103_1' tabindex='80'  /><label for='choice_103_1'>Same</label></li></ul></div></li><li id='field_1110_77' class='gfield' ><label class='gfield_label' for='input_1110_77_1'>Billing Address (If different from above)</label><div class='ginput_complex ginput_container' id='input_1110_77'><span class='ginput_full' id='input_1110_77_1_container'><input type='text' name='input_77.1' id='input_1110_77_1' value='' tabindex='81' /><label for='input_1110_77_1' id='input_1110_77_1_label'>Street Address</label></span><span class='ginput_full' id='input_1110_77_2_container' ><input type='text' name='input_77.2' id='input_1110_77_2' value='' tabindex='82' /><label for='input_1110_77_2' id='input_1110_77_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_1110_77_3_container'><input type='text' name='input_77.3' id='input_1110_77_3' value='' tabindex='83' /><label for='input_1110_77_3' id='input_1110_77.3_label'>City</label></span><span class='ginput_right' id='input_1110_77_4_container' ><select name='input_77.4' id='input_1110_77.4' tabindex='84'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_1110_77.4' id='input_1110_77_4_label'>State</label></span><span class='ginput_left' id='input_1110_77_5_container'><input type='text' name='input_77.5' id='input_1110_77_5' value='' tabindex='86' /><label for='input_1110_77_5' id='input_1110_77_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_77.6' id='input_1110_77_6' value='United States'/></div></li><li id='field_1110_109' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_112' class='gfield  gsection' ><h2 class='gsection_title'>Miscellaneous</h2></li><li id='field_1110_86' class='gfield' ><label class='gfield_label' for='input_1110_86'>Additional Comments</label><div class='ginput_container'><textarea name='input_86' id='input_1110_86' class='textarea medium' tabindex='87'  rows='10' cols='50'></textarea></div></li><li id='field_1110_69' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1110_67' class='gfield' ><label class='gfield_label' for='input_1110_67'>How did you hear about Proximo Travel?</label><div class='ginput_container'><input name='input_67' id='input_1110_67' type='text' value='' class='large'  tabindex='88'  /></div></li><li id='field_1110_110' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div>
<hr /></li><li id='field_1110_111' class='gfield  gsection' ><h2 class='gsection_title'>No Liability Agreement</h2></li><li id='field_1110_95' class='gfield               gfield_contains_required' ><label class='gfield_label'>Checking this box means that I agree that no liability is assumed by Antoine Nachef, Proximo Travel, LLC or employees of Proximo Travel, LLC for injuries to person(s) or damage to property while on any trip hosted by Proximo Travel, LLC.<span class='gfield_required'>*</span></label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1110_95'><li class='gchoice_95_1'><input name='input_95.1' type='checkbox'  value='I Agree'  id='choice_95_1' tabindex='89'  /><label for='choice_95_1'>I Agree</label></li></ul></div></li><li id='field_1110_102' class='gfield     gform_hidden' ><input name='input_102' id='input_1110_102' type='hidden' class='gform_hidden' value='' /></li>
                            </ul></div>
        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1110' class='button gform_button' value='Submit' tabindex='90' />
            <input type='hidden' class='gform_hidden' name='is_submit_1110' value='1' />
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		</item>
		<item>
		<title>Greece &amp; Turkey (2013, Sept. 23-Oct. 05)</title>
		<link>http://www.proximotravel.com/general-trips/greece-turkey-2013-sept-23-oct-05/</link>
		<comments>http://www.proximotravel.com/general-trips/greece-turkey-2013-sept-23-oct-05/#comments</comments>
		<pubDate>Mon, 20 Feb 2012 19:04:02 +0000</pubDate>
		<dc:creator>abecker</dc:creator>
				<category><![CDATA[General Trips]]></category>
		<category><![CDATA[Greece]]></category>

		<guid isPermaLink="false">http://www.proximotravel.com/?p=7948</guid>
		<description><![CDATA[Thessaloniki • Phillippi • Kavala • Kalambaka • Meteora • Delphi • Corinth • Athens • Piraeus • Mykonos • Kusadasi (Turkey) • Ephesus (Turkey) • Patmos • Santorini • Istanbul (Turkey)]]></description>
			<content:encoded><![CDATA[<h3 style="text-align: center;">Thessaloniki  • Phillippi • Kavala • Kalambaka • Meteora • Delphi • Corinth  •  Athens • Piraeus • Mykonos • Kusadasi (Turkey) • Ephesus (Turkey) •  Patmos • Santorini •  Istanbul (Turkey)</h3>
<hr />

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                            <h3 class='gform_title'>Greece & Turkey (2013, Sept. 23-Oct. 05) - Trip Registration</h3>
                            <span class='gform_description'>Please fill out the form below with your details to reserve your trip now.</span>
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>Mrs.</option><option value='Ms.' >Ms.</option></select></div></li><li id='field_1108_1' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1108_1'>First Name<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_1' id='input_1108_1' type='text' value='' class='medium'  tabindex='2'  /></div></li><li id='field_1108_4' class='gfield' ><label class='gfield_label' for='input_1108_4'>Middle Name or Initial (As it appears on passport)</label><div class='ginput_container'><input name='input_4' id='input_1108_4' type='text' value='' class='medium'  tabindex='3'  /></div></li><li id='field_1108_3' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1108_3'>Last Name<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_3' id='input_1108_3' type='text' value='' class='medium'  tabindex='4'  /></div></li><li id='field_1108_5' 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for='input_1108_20'>Gender<span class='gfield_required'>*</span></label><div class='ginput_container'><select name='input_20' id='input_1108_20'  class='medium gfield_select' tabindex='19' ><option value='' selected='selected'>Select one...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_1108_64' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_64'>Passport Number</label><div class='ginput_container'><input name='input_64' id='input_1108_64' type='text' value='' class='small'  tabindex='20'  /></div></li><li id='field_1108_68' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_68'>Country of Issuance</label><div class='ginput_container'><select name='input_68' id='input_1108_68'  class='medium gfield_select' tabindex='21' ><option value='Select one...' >Select one...</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_1108_149' class='gfield' ><label class='gfield_label' for='input_1108_149'>Date of Expiration</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1108_149'><input type='text' maxlength='2' name='input_149[]' id='input_1108_149.1' value='' tabindex='22' /><label for='input_1108_149.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1108_149'><input type='text' maxlength='2' name='input_149[]' id='input_1108_149.2' value='' tabindex='23' /><label for='input_1108_149.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1108_149'><input type='text' maxlength='4' name='input_149[]' id='input_1108_149.3' value='' tabindex='24' /><label for='input_1108_149.3'>YYYY</label></div></div></li><li id='field_1108_70' class='gfield' ><label class='gfield_label' for='input_1108_70'>Upload Passport Image</label><div class='ginput_container'><input name='input_70' id='input_1108_70' type='file' value='' size='20' class='medium' tabindex='25' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_1108_54' class='gfield      gfield_html gfield_html_formatted' ><div style="height:30px;">&nbsp;</div></li><li id='field_1108_24' class='gfield  gsection' ><h2 class='gsection_title'>Passenger  #1: Emergency Contact Information</h2></li><li id='field_1108_26' class='gfield' ><label class='gfield_label' for='input_1108_26.3'>Name</label><div class='ginput_complex ginput_container' id='input_1108_26'><span id='input_1108_26_3_container' class='ginput_left'><input type='text' name='input_26.3' id='input_1108_26_3' value='' tabindex='26' /><label for='input_1108_26_3'>First</label></span><span id='input_1108_26_6_container' class='ginput_right'><input type='text' name='input_26.6' id='input_1108_26_6' value='' tabindex='27' /><label for='input_1108_26_6'>Last</label></span></div></li><li id='field_1108_27' class='gfield' ><label class='gfield_label' for='input_1108_27'>Phone (1)</label><div class='ginput_container'><input name='input_27' id='input_1108_27' type='text' value='' class='medium' tabindex='28' /></div></li><li id='field_1108_28' class='gfield' ><label class='gfield_label' for='input_1108_28'>Phone (2)</label><div class='ginput_container'><input name='input_28' id='input_1108_28' type='text' value='' class='medium' tabindex='29' /></div></li><li id='field_1108_29' class='gfield' ><label class='gfield_label' for='input_1108_29'>Relationship</label><div class='ginput_container'><input name='input_29' id='input_1108_29' type='text' value='' class='medium'  tabindex='30'  /></div></li><li id='field_1108_49' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1108_21' class='gfield  gsection' ><h2 class='gsection_title'>Special Trip Details and Requests</h2></li><li id='field_1108_60' class='gfield               gfield_contains_required' ><label class='gfield_label' for='input_1108_60'>Departure Airport<span class='gfield_required'>*</span></label><div class='ginput_container'><input name='input_60' id='input_1108_60' type='text' value='' class='medium'  tabindex='31'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_1108_85' class='gfield' ><label class='gfield_label' for='input_1108_85'>Seating Preference</label><div class='ginput_container'><select name='input_85' id='input_1108_85'  class='medium gfield_select' tabindex='32' ><option value='Select below...' >Select below...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_1108_22' class='gfield' ><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1108_22'><li class='gchoice_22_1'><input name='input_22.1' type='checkbox'  value='*Special dietary concerns / requests'  id='choice_22_1' tabindex='33'  /><label for='choice_22_1'>*Special dietary concerns / requests</label></li><li class='gchoice_22_2'><input name='input_22.2' type='checkbox'  value='Wheelchair requirement'  id='choice_22_2' tabindex='34'  /><label for='choice_22_2'>Wheelchair requirement</label></li><li class='gchoice_22_3'><input name='input_22.3' type='checkbox'  value='Others (please contact me)'  id='choice_22_3' tabindex='35'  /><label for='choice_22_3'>Others (please contact me)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_1108_145' class='gfield' ><label class='gfield_label' for='input_1108_145'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_145' id='input_1108_145' type='text' value='' class='medium'  tabindex='36'  /></div></li><li id='field_1108_25' class='gfield' ><label class='gfield_label' for='input_1108_25'>I would like to travel and/or room with these people:</label><div class='ginput_container'><textarea name='input_25' id='input_1108_25' class='textarea small' tabindex='37'  rows='10' cols='50'></textarea></div></li><li id='field_1108_126' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1108_150' class='gfield' ><label class='gfield_label'>Registering a second passenger?</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1108_150'><li class='gchoice_150_1'><input name='input_150.1' type='checkbox' onclick='gf_apply_rules(1108,[127,129,129,121,139,121,139,128,128,123,122,124,125,140,123,122,124,125,140,130,130,131,132,133,146,147,148,134,141,131,132,133,146,147,148,134,141,135,135,143,136,137,138,142,143,136,137,138,142,30,30,31,32,33,34,48,31,32,33,34,48]);' value='Yes'  id='choice_150_1' tabindex='38'  /><label for='choice_150_1'>Yes</label></li></ul></div></li><li id='field_1108_127' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1108_129' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Name Information</h2></li><li id='field_1108_121' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_121.3'>Name as it appears on Passport</label><div class='ginput_container'><input name='input_121' id='input_1108_121' type='text' value='' class='medium' tabindex='39' /></div></li><li id='field_1108_139' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1108_128' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Contact Information (If different from Passenger #1)</h2></li><li id='field_1108_123' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_123'>Passenger #2: Email Address</label><div class='ginput_container'><input name='input_123' id='input_1108_123' type='text' value='' class='medium'  tabindex='40'  /></div></li><li id='field_1108_122' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_122_1'>Passenger #2: Address</label><div class='ginput_complex ginput_container' id='input_1108_122'><span class='ginput_full' id='input_1108_122_1_container'><input type='text' name='input_122.1' id='input_1108_122_1' value='' tabindex='41' /><label for='input_1108_122_1' id='input_1108_122_1_label'>Street Address</label></span><span class='ginput_full' id='input_1108_122_2_container' ><input type='text' name='input_122.2' id='input_1108_122_2' value='' tabindex='42' /><label for='input_1108_122_2' id='input_1108_122_2_label'>Address Line 2</label></span><span class='ginput_left' id='input_1108_122_3_container'><input type='text' name='input_122.3' id='input_1108_122_3' value='' tabindex='43' /><label for='input_1108_122_3' id='input_1108_122.3_label'>City</label></span><span class='ginput_right' id='input_1108_122_4_container' ><select name='input_122.4' id='input_1108_122.4' tabindex='44'   ><option value='' selected='selected'></option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option><option value='Armed Forces Americas' >Armed Forces Americas</option><option value='Armed Forces Europe' >Armed Forces Europe</option><option value='Armed Forces Pacific' >Armed Forces Pacific</option></select><label for='input_1108_122.4' id='input_1108_122_4_label'>State</label></span><span class='ginput_left' id='input_1108_122_5_container'><input type='text' name='input_122.5' id='input_1108_122_5' value='' tabindex='46' /><label for='input_1108_122_5' id='input_1108_122_5_label'>Zip Code</label></span><input type='hidden' class='gform_hidden' name='input_122.6' id='input_1108_122_6' value='United States'/></div></li><li id='field_1108_124' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_124'>Passenger #2: Phone (1)</label><div class='ginput_container'><input name='input_124' id='input_1108_124' type='text' value='' class='medium' tabindex='47' /></div></li><li id='field_1108_125' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_125'>Passenger #2: Phone (2)</label><div class='ginput_container'><input name='input_125' id='input_1108_125' type='text' value='' class='medium' tabindex='48' /></div></li><li id='field_1108_140' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1108_130' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Passport Information</h2></li><li id='field_1108_131' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_131'>Do you have a Passport?</label><div class='ginput_container'><select name='input_131' id='input_1108_131'  class='small gfield_select' tabindex='49' ><option value='Please select ...' >Please select ...</option><option value='Yes' >Yes</option><option value='No' >No</option></select></div></li><li id='field_1108_132' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_132'>Date of Birth</label><div class='clear-multi'><div class='gfield_date_month ginput_container' id='input_1108_132'><input type='text' maxlength='2' name='input_132[]' id='input_1108_132.1' value='' tabindex='50' /><label for='input_1108_132.1'>MM</label></div><div class='gfield_date_day ginput_container' id='input_1108_132'><input type='text' maxlength='2' name='input_132[]' id='input_1108_132.2' value='' tabindex='51' /><label for='input_1108_132.2'>DD</label></div><div class='gfield_date_year ginput_container' id='input_1108_132'><input type='text' maxlength='4' name='input_132[]' id='input_1108_132.3' value='' tabindex='52' /><label for='input_1108_132.3'>YYYY</label></div></div></li><li id='field_1108_133' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_133'>Gender</label><div class='ginput_container'><select name='input_133' id='input_1108_133'  class='small gfield_select' tabindex='53' ><option value='Please select ...' >Please select ...</option><option value='Male' >Male</option><option value='Female' >Female</option></select></div></li><li id='field_1108_146' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_146'>Passport Number</label><div class='ginput_container'><input name='input_146' id='input_1108_146' type='text' value='' class='medium'  tabindex='54'  /></div></li><li id='field_1108_147' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_147'>Country of Issuance:</label><div class='ginput_container'><select name='input_147' id='input_1108_147'  class='medium gfield_select' tabindex='55' ><option value='Please select...' >Please select...</option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Brazil' >Brazil</option><option value='Brunei' >Brunei</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo' >Congo</option><option value='Costa Rica' >Costa Rica</option><option value='C&ocirc;te d&#039;Ivoire' >C&ocirc;te d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='East Timor' >East Timor</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Ethiopia' >Ethiopia</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='North Korea' >North Korea</option><option value='South Korea' >South Korea</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Laos' >Laos</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Norway' >Norway</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine' >Palestine</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia and Montenegro' >Serbia and Montenegro</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Swaziland' >Swaziland</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Togo' >Togo</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Vatican City' >Vatican City</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option></select></div></li><li id='field_1108_148' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_148'>Date of Expiration</label><div class='ginput_container'><input name='input_148' id='input_1108_148' type='text' value='' class='datepicker medium mdy datepicker_no_icon' tabindex='56' /> </div><input type='hidden' id='gforms_calendar_icon_input_1108_148' class='gform_hidden' value='http://www.proximotravel.com/website/wp-content/plugins/gravityforms/images/calendar.png'/></li><li id='field_1108_134' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_134'>Upload Passport Image</label><div class='ginput_container'><input name='input_134' id='input_1108_134' type='file' value='' size='20' class='medium' tabindex='57' /></div><div class='gfield_description'>Scan a copy of the inside of your passport and upload the image (Possible file formats: jpg, gif, png, pdf)</div></li><li id='field_1108_141' class='gfield      gfield_html gfield_html_formatted' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1108_135' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Special Trip Details &amp; Requests</h2></li><li id='field_1108_143' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_143'>Passenger #2: Departure Airport</label><div class='ginput_container'><input name='input_143' id='input_1108_143' type='text' value='' class='medium'  tabindex='58'  /></div><div class='gfield_description'>Please include the airport that you would like to depart from</div></li><li id='field_1108_136' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_136'>Seat Preferences</label><div class='ginput_container'><select name='input_136' id='input_1108_136'  class='medium gfield_select' tabindex='59' ><option value='Select below ...' >Select below ...</option><option value='Window Seat' >Window Seat</option><option value='Middle Seat' >Middle Seat</option><option value='Aisle Seat' >Aisle Seat</option><option value='No Preference' >No Preference</option></select></div></li><li id='field_1108_137' class='gfield' style='display:none;'><label class='gfield_label'>I have the following special requests:</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1108_137'><li class='gchoice_137_1'><input name='input_137.1' type='checkbox'  value='*Special dietary concernes/requests'  id='choice_137_1' tabindex='60'  /><label for='choice_137_1'>*Special dietary concernes/requests</label></li><li class='gchoice_137_2'><input name='input_137.2' type='checkbox'  value='Wheelchair requirements'  id='choice_137_2' tabindex='61'  /><label for='choice_137_2'>Wheelchair requirements</label></li><li class='gchoice_137_3'><input name='input_137.3' type='checkbox'  value='Others (Please contact me.)'  id='choice_137_3' tabindex='62'  /><label for='choice_137_3'>Others (Please contact me.)</label></li></ul></div><div class='gfield_description'>Please select all that apply.</div></li><li id='field_1108_138' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_138'>*List dietary concerns/requests</label><div class='ginput_container'><input name='input_138' id='input_1108_138' type='text' value='' class='medium'  tabindex='63'  /></div></li><li id='field_1108_142' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1108_30' class='gfield  gsection' style='display:none;'><h2 class='gsection_title'>Passenger #2: Emergency Contact Information </h2></li><li id='field_1108_31' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_31.3'>Name</label><div class='ginput_complex ginput_container' id='input_1108_31'><span id='input_1108_31_3_container' class='ginput_left'><input type='text' name='input_31.3' id='input_1108_31_3' value='' tabindex='64' /><label for='input_1108_31_3'>First</label></span><span id='input_1108_31_6_container' class='ginput_right'><input type='text' name='input_31.6' id='input_1108_31_6' value='' tabindex='65' /><label for='input_1108_31_6'>Last</label></span></div></li><li id='field_1108_32' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_32'>Phone (1)</label><div class='ginput_container'><input name='input_32' id='input_1108_32' type='text' value='' class='medium' tabindex='66' /></div></li><li id='field_1108_33' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_33'>Phone (2)</label><div class='ginput_container'><input name='input_33' id='input_1108_33' type='text' value='' class='medium' tabindex='67' /></div></li><li id='field_1108_34' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_34'>Relationship</label><div class='ginput_container'><input name='input_34' id='input_1108_34' type='text' value='' class='medium'  tabindex='68'  /></div></li><li id='field_1108_48' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' style='display:none;'><div style="height:30px;">&nbsp;</div></li><li id='field_1108_38' class='gfield  gsection' ><h2 class='gsection_title'>Purchasing Options</h2><div class='gsection_description'>In order to register and save your place on the trip, a $500 non-refundable deposit is required per passenger.  Payment in full must be received at 857 West Boylston St. Worcester, MA 01606, 90 days prior to trip date.</div></li><li id='field_1108_119' class='gfield           gfield_price gfield_price_1108_119 gfield_product_1108_119' ><label class='gfield_label' for='input_1108_119'>*Total Trip Price</label><div class='ginput_container'><input type='hidden' name='input_119.1' value='*Total Trip Price' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1108_119'>$4,824.97</span><input type='hidden' name='input_119.2' id='ginput_base_price_1108_119' class='gform_hidden' value='$4,824.97'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_119.3' value='' id='ginput_quantity_1108_119' class='ginput_quantity' size='10' tabindex='69'/></div><div class='gfield_description'>* There is NO 3% credit/debit card surcharge for the initial deposit or travel cancellation protection. If payment is made in full, the 3% credit/debit card surcharge applies ONLY to the cost of the trip less the deposit and travel cancellation protection (if purchased).
For this trip, the 3% credit/debit surcharge is $125.97.</div></li><li id='field_1108_116' class='gfield           gfield_price gfield_price_1108_116 gfield_product_1108_116' ><label class='gfield_label' for='input_1108_116'>Deposit</label><div class='ginput_container'><input type='hidden' name='input_116.1' value='Deposit' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1108_116'>$500.00</span><input type='hidden' name='input_116.2' id='ginput_base_price_1108_116' class='gform_hidden' value='$500.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_116.3' value='' id='ginput_quantity_1108_116' class='ginput_quantity' size='10' tabindex='70'/></div></li><li id='field_1108_117' class='gfield           gfield_price gfield_price_1108_117 gfield_product_1108_117' ><label class='gfield_label' for='input_1108_117'>Travel Cancellation Protection</label><div class='ginput_container'><input type='hidden' name='input_117.1' value='Travel Cancellation Protection' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1108_117'>$200.00</span><input type='hidden' name='input_117.2' id='ginput_base_price_1108_117' class='gform_hidden' value='$200.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_117.3' value='' id='ginput_quantity_1108_117' class='ginput_quantity' size='10' tabindex='71'/></div></li><li id='field_1108_115' class='gfield           gfield_price gfield_price_1108_115 gfield_product_1108_115' ><label class='gfield_label' for='input_1108_115'>Single Supplement</label><div class='ginput_container'><input type='hidden' name='input_115.1' value='Single Supplement' class='gform_hidden' /><span class='ginput_product_price_label'>Price:</span> <span class='ginput_product_price' id='input_1108_115'>$700.00</span><input type='hidden' name='input_115.2' id='ginput_base_price_1108_115' class='gform_hidden' value='$700.00'/> <span class='ginput_quantity_label'>Quantity:</span> <input type='text' name='input_115.3' value='' id='ginput_quantity_1108_115' class='ginput_quantity' size='10' tabindex='72'/></div><div class='gfield_description'>If you are traveling by yourself and prefer your own room.</div></li><li id='field_1108_96' class='gfield            gfield_price gfield_price_1108_96 gfield_donation_1108_96' ><label class='gfield_label' for='input_1108_96'>Custom Amount</label><div class='ginput_container'><input name='input_96' id='input_1108_96' type='text' value='' class='medium' tabindex='73' /></div></li><li id='field_1108_46' class='gfield' ><label class='gfield_label' for='input_1108_46'>Total</label><div class='ginput_container'><span class='ginput_total ginput_total_1108'>$0.00</span><input type='hidden' name='input_46' id='input_1108_46' class='gform_hidden'/></div></li><li id='field_1108_108' class='gfield      gfield_html gfield_html_formatted gfield_no_follows_desc' ><div style="height:30px;">&nbsp;</div></li><li id='field_1108_73' class='gfield  gsection' ><h2 class='gsection_title'>Payment Information</h2></li><li id='field_1108_79' class='gfield' ><label class='gfield_label' for='input_1108_79'>Payment Type</label><div class='ginput_container'><select name='input_79' id='input_1108_79' onchange='gf_apply_rules(1108,[97,98,99,100,101]);' class='medium gfield_select' tabindex='74' ><option value='Credit Card or Debit Card' >Credit Card or Debit Card</option><option value='Money Order' >Money Order</option><option value='Cash' >Cash</option><option value='Check' >Check</option></select></div></li><li id='field_1108_97' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_97'>Name On Card</label><div class='ginput_container'><input name='input_97' id='input_1108_97' type='text' value='' class='medium'  tabindex='75'  /></div></li><li id='field_1108_98' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_98'>Credit Card or Debit Card Number</label><div class='ginput_container'><input name='input_98' id='input_1108_98' type='text' value='' class='medium' tabindex='76' /></div></li><li id='field_1108_99' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_99'>CVV</label><div class='ginput_container'><input name='input_99' id='input_1108_99' type='text' value='' class='small' tabindex='77' /></div></li><li id='field_1108_100' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_100'>Expiration Month</label><div class='ginput_container'><select name='input_100' id='input_1108_100'  class='small gfield_select' tabindex='78' ><option value='01' >January</option><option value='02' >February</option><option value='03' >March</option><option value='04' >April</option><option value='05' >May</option><option value='06' >June</option><option value='07' >July</option><option value='08' >August</option><option value='09' >September</option><option value='10' >October</option><option value='11' >November</option><option value='12' >December</option></select></div></li><li id='field_1108_101' class='gfield' style='display:none;'><label class='gfield_label' for='input_1108_101'>Expiration Year</label><div class='ginput_container'><select name='input_101' id='input_1108_101'  class='small gfield_select' tabindex='79' ><option value='12' >2012</option><option value='13' >2013</option><option value='14' >2014</option><option value='15' >2015</option><option value='16' >2016</option><option value='17' >2017</option><option value='18' >2018</option><option value='19' >2019</option><option value='20' >2020</option><option value='21' >2021</option><option value='22' >2022</option><option value='23' >2023</option><option value='24' >2024</option><option value='25' >2025</option></select></div></li><li id='field_1108_103' class='gfield' ><label class='gfield_label'>Check if Billing Address and Mailing Address are the same.</label><div class='ginput_container'><ul class='gfield_checkbox' id='input_1108_103'><li class='gchoice_103_1'><input name='input_103.1' type='checkbox' onclick='gf_apply_rules(1108,[77]);' value='Same'  id='choice_103_1' tabindex='80'  /><label for='choice_103_1'>Same</label></li></ul></div></li><li id='field_1108_77' class='gfield' ><label class='gfield_label' for='input_1108_77_1'>Billing Address (If different from above)</label><div class='ginput_complex ginput_container' id='input_1108_77'><span class='ginput_full' id='input_1108_77_1_container'><input type='text' name='input_77.1' id='input_1108_77_1' value='' tabindex='81' /><label for='input_1108_77_1' id='input_1108_77_1_label'>Street Address</label></span><span class='ginput_full' id='input_1108_77_2_container' ><input type='text' name='input_77.2' id='input_1108_77_2' value='' tabindex='82' /><label for='input_1108_77_2' 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			<wfw:commentRss>http://www.proximotravel.com/general-trips/greece-turkey-2013-sept-23-oct-05/feed/</wfw:commentRss>
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		</item>
		<item>
		<title>Greece &amp; Turkey (2013, May 04-16)</title>
		<link>http://www.proximotravel.com/general-trips/greece-turkey-2013-may-04-16/</link>
		<comments>http://www.proximotravel.com/general-trips/greece-turkey-2013-may-04-16/#comments</comments>
		<pubDate>Mon, 20 Feb 2012 19:02:38 +0000</pubDate>
		<dc:creator>abecker</dc:creator>
				<category><![CDATA[General Trips]]></category>
		<category><![CDATA[Greece]]></category>

		<guid isPermaLink="false">http://www.proximotravel.com/?p=7945</guid>
		<description><![CDATA[Thessaloniki • Phillippi • Kavala • Kalambaka • Meteora • Delphi • Corinth • Athens • Piraeus • Mykonos • Kusadasi (Turkey) • Ephesus (Turkey) • Patmos • Santorini • Istanbul (Turkey)]]></description>
			<content:encoded><![CDATA[<h3 style="text-align: center;">Thessaloniki  • Phillippi • Kavala • Kalambaka • Meteora • Delphi • Corinth  •  Athens • Piraeus • Mykonos • Kusadasi (Turkey) • Ephesus (Turkey) •  Patmos • Santorini •  Istanbul (Turkey)</h3>
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                            <h3 class='gform_title'>Greece & Turkey (2013, May 04-16) - Trip Registration</h3>
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