asiahighlights.com/application/views/orders/form-advanced.php

<style>
.datepicker table tr td.disabled{
	color:#999;
}
</style>
<link href="/css/form-advanced.css" rel="stylesheet">
<div id="formBanner">
<h1>Start planning your journey</h1>
<div class="procedure hidden-xs">
<div class="container">
<span class="subTitle">How we create your itinerary</span>
<div class="row">
<div class="col-md-5 col-sm-5"><span class="listIcon">Use the form below 
to make an inqury 
with us</span></div>
<div class="col-md-1 col-sm-1"><span class="whiteBorder"></span></div>
<div class="col-md-5 col-sm-5"><span class="peopleIcon">We get in touch 
with you within 24 
hours with suggestions</span></div>
<div class="col-md-1 col-sm-1"><span class="whiteBorder"></span></div>
<div class="col-md-6 col-sm-6"><span class="emailIcon">We then craft  
an intinerary 
proposal based 
on your interests</span></div>
<div class="col-md-1 col-sm-1"><span class="whiteBorder"></span></div>
<div class="col-md-5 col-sm-5"><span class="handIcon">We work with you to 
refine the itinerary 
until you are satisfied</span></div>
</div> 
</div>
</div>
</div>
<div class="container">
<div class="row">
<div class="col-md-17 col-sm-17 col-xs-24">
<div id="inquiryBox">
<form action="<?php echo $action;?>" method="post" id="form_tailormade" name="form_tailormade" >
<h2>Tell us about your travel plan</h2>
<span class="labelTitle">Destination(s)<sup>*</sup></span>
<div class="destinations" id="destinations">
<ul>
<?php 
	foreach($countrylist as $value){
		if(in_array($value,$countryarr)){
			echo '<li class="checked" name="'.$value.'"><label><input type="hidden" value="'.$value.'"> '.$value.'</label></li>';
		}else{
			echo '<li name="'.$value.'"><label><input type="hidden" value="'.$value.'"> '.$value.'</label></li>';
		}
	}	
	echo '</ul>';
	echo '<input type="hidden" value="" name="Destination"/>';
	echo '</div>';
	if(isset($ic_title)){
		echo '<span class="interestedIn" style="font-style:italic;">Interested in the itinerary: ”'.$ic_title.'”</span>';
	}
	
?>
<span class="labelTitle">Date of arrival <sup>*</sup></span>
<div class="row">
<div class="col-md-12 col-sm-12 col-xs-24">
<input type="text" class="arrivalDate datepicker" id="Date_Start" name="Date_Start" value="" placeholder="mm/dd/yyyy" autocomplete="off">
</div>
<div class="col-md-12 col-sm-12 col-xs-24" style="padding-left:40px">
<li class="flexibleDate">
<label><input type="hidden"> I'm flexible on the date</label>
<input type="hidden" name="FlexibleDate" value="No"/>
</li>
</div>
</div>
<span class="labelTitle">Hotel style <sup>*</sup>
<div class="HotelStyle" id="HotelStyle">
<p style="font-size=14px;color:#999;">*Hotels prices in Japan are at least doubled based on the suggested rates below.</p>
<ul>
<li name="Luxury (5 stars & up)"><label><input type="hidden" value="Luxury" id="fiveStar"> Luxury (5 stars & up) <em>USD 200+ / room / night</em></label></li>
<li name="Handpicked Comfort (4-5 stars)"><label><input type="hidden" value="Handpiched Comfort" id="fourStar"> 
Handpicked Comfort (4-5 stars) <em>USD 100-200 / room / night</em></label></li>
<li name="Standard (3 stars)"><label><input type="hidden" value="Standard" id="threeStar"> 
Standard (3 stars)<em>USD 70-100 / room / night</em></label></li>
</ul>
<input type="hidden" value="" name="HotelStyle"/>
</div>
<span class="labelTitle">Tell us more to help us put together your ideal journey <sup>*</sup> </span>
<textarea id="additionalrequirements" name="additionalrequirements" style="resize:none;" placeholder="E.g. group size, duration, first time to Asia, family orientated, vacation, business, your interests - culture, hiking, food, photography etc..."></textarea>
</div>
<div id="contactInfo">
<h2>Your details</h2>
<div class="row">
<div class="col-md-4 col-sm-4 col-xs-24"><span class="subTitle">Title <sup>*</sup></span>
<select id="Title" name="Title" style="height:38px;background-position:center right 10px;">
<option value=""></option>
<option value="Mr">Mr</option>
<option value="Mrs">Mrs</option>
<option value="Ms">Ms</option>
</select>
</div>
<div class="col-md-10 col-sm-10 col-xs-12">
<span class="subTitle">First name <sup>*</sup></span>
<input style="width:90%;" type="text" class="firstname" type="text" name="Firstname" id="Firstname">
</div>
<div class="col-md-10 col-sm-10 col-xs-12">
<span class="subTitle">Last name <sup>*</sup></span>
<input style="width:90%;" type="text" class="lastname" type="text" name="Lastname" id="Lastname">
</div>
<div class="clearfix"></div>
<div class="col-md-12 col-sm-12 col-xs-24">
<span class="labelTitle">Email address <sup>*</sup></span>
<input type="email" name="email" id="email">
</div>
<div class="clearfix"></div>
<div class="col-md-12 col-sm-12 col-xs-24">
<span class="labelTitle">Nationality<sup>*</sup></span>
<input type="text" placeholder="United States" name="Nationality" id="Nationality"/>
</div>
<div class="clearfix"></div>
<div class="col-md-12 col-sm-12 col-xs-24">
<span class="labelTitle">Phone number</span>
<input type="tel" placeholder="(+1)" class="telephone" name="PhoneNo" id="PhoneNo">
</div>
<div class="col-md-12 col-sm-12 col-xs-24">
<span class="onlyCall">Only call if you ask, or for email issues</span>
</div>
</div>
</div>

<div class="row">
<div class="col-md-14 col-sm-14 hidden-xs"></div>
<div class="col-md-10 col-sm-10 col-xs-24">
<div class="submitBtn">
<span class="beginNow"><a style="cursor:pointer;" onclick="submitForm('form_tailormade');">Begin my journey <i class="fa fa-angle-right" aria-hidden="true"></i></a></span>
We never pass your information onto a third party.  After submitting this form you will receive an email confirmation and from time to time our newsletters.
</div>
</div>
</div>
</div>
<div class="col-md-7 col-sm-7 hidden-xs">
<div class="formTrust">
<h2>Recognized</h2>
<img src="/pic/featured-in.png" class="img-responsive">
<div class="monkReview">
"I can definitely recommend Asia Highlights and Albee if you are planning to book a trip to Myanmar and I will use them again if we are going to travel to any of the destinations on offer." 
<b>Frank S</b>
</div>
</div>
</div>
<?php if(isset($cli_no)){?>
	<input type="hidden" name="cli_no" value="<?php echo $cli_no?>"/>
<?php } ?>
<?php if(isset($cli_sn)){?>
	<input type="hidden" name="cli_sn" value="<?php echo $cli_sn?>"/>
<?php } ?>
<?php if(isset($cli_days)){?>
	<input type="hidden" name="cli_days" value="<?php echo $cli_days?>"/>
<?php } ?>
</form>
</div>
</div>
<script>
$(function(){
	//目的地选择效果
	$('.destinations li').click(function(){
		if($(this).hasClass('checked')){
			$(this).removeClass('checked');
		}else{
			$(this).addClass('checked');
		}
	});
	
	//flexibleDate选择效果
	$('.flexibleDate').click(function(){
		if($(this).hasClass('checked')){
			$(this).removeClass('checked');
			$('input[name="FlexibleDate"]').val('No');
		}else{
			$(this).addClass('checked');
			$('input[name="FlexibleDate"]').val('Yes');
		}
	});
	
	//Hotel style选择效果
	$('.HotelStyle li').click(function(){
		if($(this).hasClass('checked')){
			$(this).removeClass('checked');
			$('input[name="HotelStyle"]').val('');
		}else{
			$('.HotelStyle li').removeClass('checked');
			$(this).addClass('checked');
			$('input[name="HotelStyle"]').val($(this).attr('name'));
		}
	});
	
	$('input[name="Nationality"]').bind("input propertychange change",function(event){
        if($(this).val() == 'United States'){
			$("#PhoneNo").val('+1');
		}else{
			$("#PhoneNo").attr('placeholder','');
		}
	});
	
});
</script>