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WMT's
Ultimate Panama Canal
November
4-20, 2010
Registration Form
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:___________________
Princess Captain Circle Numbers (1)________________________
(2)____________________
Cabin: Mini-Suite (AC) Oversized w/Balcony (BA) Balcony (BB), (BC) or
(BD) Ocean view (EE) Interior (JJ)
Bed configuration: 2 Twin Queen Smoking Non Smoking
Celebrating a Special Occasion:
___________________________________________________
PASSPORT
INFORMATION
All
passengers are required to have a passport valid through May 21, 2011.
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 to
Alaska should be in reasonably good health. Please consult your physician
for pre-departure health advice. We regret that we cannot provide
individual assistance to guests with walking, dining or other personal
needs. We suggest that an able companion accompany persons needing such
assistance.
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.
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.
_____Yes _____No 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).
______ 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:
$700.00 per person is due with reservation. Final payment due on or before
August 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
CANCELLATION
POLICY
Date
Cancellation Fee
Date of
deposit to July 31, 2010 $700 per person
August 1,
2010 or
later
Nonrefundable
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:
Destinations
Unlimited, inc |
