Tour Application

SELECTOURS TRAVEL TOUR PARTICIPANT APPLICATION

CLIA

Name of trip

Please complete this entire form and be sure to sign it. (Those living at different addresses should use separate forms)

Departure Date

Your full name(s) exactly as it is on your passport :

(1) First Name

Middle Name

Last Name

Email Address#1:

Birth Date

(2) First Name

Middle Name

Last Name

Email Address#2:

Birth Date

Home Address

City

State

Zip

(1) Work phone

Home phone

Occupation

(2) Work phone

Home phone

Occupation

Address for U.P.S. or Express Mail (No P.O. or General Deliveries)

Address

City

State

Zip

Sharing room with:

Or Requesting single supplement: [ ] Cabin Type Requested:

1. Medical problems:

Allergies:

2. Medical problems:

Allergies:

1. Dietary restrictions:

Seating Preference: (F,M,L)

2. Dietary restrictions:

Passport information: (Not needed for Domestic Trips)

1. Number:

Citizenship:

Birthdate:

Passport expiration date/Date exp:

2. Number:

Citizenship:

Birthdate:

Passport expiration date/Date exp:

Please book my air itinerary from(Airport)

returning to (Airport)

1. Airline meal preference:

Seating pref:

Freq. flier #

2. Airline meal preference:

Seating pref:

Freq. flier #

1. AMX/Visa/MC #

Exp.

CCV

hereby authorize Selectours Travel or other vendors to charge my credit card as shown above.

Name On Card:

Address:

Zip

Authorizing signature:

2. AMX/Visa/MC #

Exp.

CCV

hereby authorize Selectours Travel or other vendors to charge my credit card as shown above.

Name On Card:

Address:

Zip

Authorizing signature:

In case of emergency, please notify:

1. Name

Relation:

Phone (day):

Address:

Email Address#1:

Phone (Evening):

2. Name

Relation:

Phone (day):

Address:

Email Address#2:

Phone (Evening):

1. I have read the terms section on the back of the trip brochure and I have also read the Terms and Conditions of Passage printed on the reverse of this application and agree to be bound by the terms contained therein. I hereby authorize Selectours Travel and Holland America Line to charge my credit card as shown above.

Applicants signature

Date:

SELECTOURS TRAVEL

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