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REGISTRATION
FORM
WMT’s
Highlights of Eastern Europe
September
5-19, 2010
TRAVELER INFORMATION
**IMPORTANT** You must print your name EXACTLY as it appears on your
passport. If the name on this form does not match your passport, you may
be denied boarding or subject to a revision fee.
(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:
_____________________
Bed configuration request: 2
Twin
Queen
Smoking Non Smoking
Celebrating a Special Occasion:
___________________________________________________
PASSPORT
INFORMATION
All
passengers are required to have a passport valid through March 20, 2011.
We request a copy of your passport
to be on
file in our office. Non-US citizens must advise nationality at time of
deposit.
Passport Number: (1)______________________________________ Exp.
Date:______________
Passport Number: (2)______________________________________ Exp.
Date:______________
EMERGENCY
CONTACT INFORMATION
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:___________
HEALTH AND
MEDICAL INFORMATION
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.
OPTIONAL AIR
______ 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.)
CANCELLATION POLICY
Date
Cancellation Fee
Date of deposit to July 1, 2010 $600 per
person
July 2, 2010 or
later
Nonrefundable
TRAVEL
INSURANCE
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,
we request that you 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.
PAYMENT
INFORMATION
Deposit:
$600.00 per person is due with reservation. Final payment due on or before
July 1, 2010.
If paying
with credit card, please complete and sign below. I agree to pay according
to card issuer agreement.
Type of card______________ 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:
____________________
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