(1) (Mr., Mrs., Ms., Dr., Rev.) First___________ Middle___________ Last ______________ Birth Date

(2) (Mr., Mrs., Ms., Dr., Rev.) First___________ Middle___________ Last ______________Birth Date

List how you would like your name to appear on your name badge (1) (2) ______________

Address ___________________________________________________________________________________

City ___________________________________________ State _____________ Zip

Daytime Phone: __________________________ Evening Phone: ___________________________________

E-mail address: _____________________________ Cell Phone: _____________________________________

Cunard World Club Numbers (1)_____________________________ (2)

Celebrating a Special Occasion: ________________________________________________________________

Queen Mary 2 Cabin Category (Please circle one) A1 A2 B1 B2 C1 C2 D3 D4 D5

Room Request (Please circle your selections): 2 Twin Queen Smoking Non Smoking

Are you a Brucemore Member? Yes No (Special pricing is available for Brucemore Members. Please see brochure insert.)

All passengers are required to have a passport valid through March 23, 2011. We request a copy of your passport

to be on file in our office. Non-US citizens must advise nationality at time of reservation.

Passport Number: (1)____________________________________________ Exp. Date:___________________

Passport Number: (2)____________________________________________ Exp. Date:___________________

In case of an emergency while you are traveling, please provide the following information:

Contact Name:_________________________________________ Relationship: _________________________

Daytime phone:___________________ Evening phone:__________________ Cell phone:_________________

Address:__________________________________________City:______________State:____ Zip:___________

Travelers on this tour should be in reasonably good health. Some of the included components may not be able to accommodate those with special needs. We regret that we cannot provide individual assistance to guests with walking, dining or other personal needs.

Are there any medical conditions that could require assistance?

Please advise: ______________________________________________________________________________

Do you have a physical, medical or other condition that could adversely affect you or others on this tour:

Yes        No

If yes, please explain in detail.

______ Yes, I would like more information about the optional group air arrangements.

______ No, I do not want to purchase group air. I will make my own flight arrangements.

(Restrictions as to arrival and departure flight times may apply. Please ask for more information.)

Deposit of $750.00 is required at the time of reservation and is nonrefundable.

Final payment is due June 1, 2010 and is nonrefundable.

We highly recommend that all passengers purchase travel insurance. Destinations Unlimited, inc./Travel Leaders offers Access America comprehensive travel, medical and cancellation or interruption insurance. For complete details, please read the brochure. Pre-existing conditions are covered if the full insurance premium is paid within 14 days of paying your initial trip deposit, some limitations apply. The premium is nonrefundable. If you decline Access America, we strongly advise the purchase of travel insurance through another broker. (Please check one)

______ Yes, I would like to purchase travel insurance to protect my investment. I have been advised of the

cost of this coverage.

If yes, would you like to add the optional BizPack protection at $24.00 per person for Trip Cancellation/ Interruption benefits for covered business related reasons (Required to work, business/company merger, business unsuitable due to fire, flood, natural disaster, or burglary). _____Yes _____No

______  No, I am not interested in travel insurance and acknowledge that I have been offered coverage, but choose to decline. I understand the terms of the cancellation policy.

______  Please supply me with information regarding travel insurance. I understand that the travel insurance policy

will not be purchased until my approval is given and cancellation penalties will apply.

Deposit: $750.00 per person is due with at the time of registration. Final payment due on or before June 1, 2010.

If paying with credit card, please complete and sign below. I agree to pay according to card issuer agreement.

Type of card______________ (American Express Platinum or Centurion Cardholders may qualify for additional amenities from Cunard)

Card Number______________________________________________________________________________

Expiration date_________________ 3-digit security code ______ Amount charged ______________________

____________________________________________________________ ___________________________

Cardholder's signature                                                                                         Date

I/we have received, read and agree to the Terms and Conditions of the tour.

I/we have been offered travel insurance and advised of cancellation penalties.

I/we have verified that our names are printed on this form exactly as on my/our Passports.

Signature: _______________________________________________________ Date:_____________________

Signature: _______________________________________________________ Date:_____________________

Make checks payable to:

5020 Council St. NE Cedar Rapids IA 52402

Telephone: (319) 393-1359; (800) 391-1359; Fax: (319) 393-7616

e-mail: travel@duagency.com ~ www.duagency.com