REGISTRATION FORM
November
26 29, 2007
Please print your
name as it appears on your government issued identification:
Spouse or roommate
______________________________________ Birth Date
Address
City
_________________________________
State _____________ Zip
Daytime Phone:
_______________________ Evening
Phone:
E-mail address:
ญญญญญญญญญญญญญญญญญญญญญญญญ_____________________________ Cell Phone:
Phone number we can reach you the night before
departure:
_____________________________
Type of Room: Smoking Non-Smoking (Please circle one)
Single Double
Triple Quad (Please circle one)
Celebrating a Special Occasion:
___________________________________________________
______
Yes, I would like to purchase the optional Andy Williams Show tickets at an
additional cost of $49.00 per person.
______
No, I do not want to purchase the optional Andy Williams Show tickets.
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
to Branson 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.
Please sign the back of this form*
We
highly recommend that all passengers purchase travel insurance. Carlson Travel/Destinations Unlimited offers
Access America comprehensive travel, medical and cancellation or interruption
insurance. For complete details, we
request 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. The premium is non-refundable. If you decline Access America, we strongly
advise the purchase of travel insurance through another broker.
______ Yes, please supply me with information
regarding travel insurance. I
understand this purchase
will not be made until my
approval is given.
______ No, I am not interested in travel
insurance and acknowledge that I have been offered
coverage, but choose to decline.
From
time of deposit to October 5, 2007 $50 per person
From
October 6, 2007 to Departure No Refund
PAYMENT INFORMATION
Deposit: $50.00 per person is due with reservation
and is non-refundable.
Final
payment due on or before October 5, 2007.
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.
Signature:
____________________________________________
Date:____________________
Signature:
____________________________________________
Date: ____________________
Make
checks payable to:
and
mail or visit our office at:
5020
Council St. NE Cedar Rapids IA 52402
Telephone: (319) 393-1359; (800) 391-1359; Fax: (319) 393-7616
e-mail:
groups@duagency.com ~
www.duagency.com