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REGISTRATION
FORM
Jewels of
Southeast Asia
March
9-29, 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:
ญญญญญญญญญญญญญญญญญญญญญญญญ_____________________________
Cell Phone:
Bed configuration:
2 Twin
Queen
Smoking
Non Smoking
Celebrating a Special
Occasion:
PASSPORT
INFORMATION
All passengers are required to have a
passport valid through October 1, 2010.
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
should be in reasonably good health. This
trip will include walking ability to climb stairs.
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.
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.)
(OVER)
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 cancellation policy
will not apply until
my approval is given for this purchase.
PAYMENT INFORMATION
Deposit:
$750.00 per person is due with reservation.
Final payment due on or before December 7, 2009.
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 December 7, 2009
$750 per person
December
7, 2009 or after
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
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
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