<label> Select an agency:
[select* SelectAgency include_blank 
"All Laos Service - LPQLR250A" 
"All Time Travel Service - VTELR250H" 
"Bluebird Ticketing Service - VTELR250D" 
"Dao Heuang Air Booking - PKZLR2502" 
"Diethelm Travel (Vientiane Branch) - VTELR250S" 
"Joy Travel - VTELR250E" 
"Keomany Air Booking Service - VTELR2523" 
"Kian Min Laos - VTELR2517" 
"Lao Air Service - VTELR250P" 
"Lao American Enterprise - VTELR2533" 
"Lao American Enterprise (LPQ Branch) - LPQLR2511" 
"Lao ko inter ticketing & Tour - LPQLR2525"
"Lao Sky Air Booking - VTELR2522" 
"Lin Travel Service - VTELR254F"
"Oudomsin Trading & Travel Service - VTELR2525" 
"Scenic Travel - VTELR2518" 
"Thai's Express - VTELR250F" 
"Trans-Express - VTELR250C" 
"Vientiane Ticketing Service - VTELR250M" 
"Viva Travel Express - LPQLR2520" 
] </label>

[radio Action default:1 "Temporary Suspend" "Reactivate"]

<label> Remark: 
[textarea Remark x4] </label>

<label> Your Name (required)
[text* your-name default:user_display_name] </label>

<label> Your Email (required)
    [email* your-email default:user_email] </label>



[submit "Send"]