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GENERAL INFORMATION
Name(s) as they appear on your passport.
____________________ _____________________ ______________________
Birthdate: __________________
First
Middle
Last
____________________ _____________________ ______________________ Birthdate:
__________________
First
Middle
Last
____________________ _____________________ ______________________ Birthdate:
__________________
First
Middle
Last
____________________ _____________________ ______________________ Birthdate:
__________________
First
Middle
Last
Address:_______________________________________ _______________________ ________ ______________
City
State Zip
WPhone: (___)_______________ X_________ HPhone:(___)_________________
Fax:_(____)___________________
Cell Phones: _(___)____________________________________________Second Phone #: ( ___)_________________
E-mails:
__________________________________ ____________________________________________________
Best time to reach you:
_____________________________________________________________________________
If anyone has different addresses, phone or fax numbers, please write them on the back of this form. ==================================================================================
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EMERGENCY CONTACT INFORMATION
Emergency Contact: Name:______________________________________ Relationship:
_________________________
Address (City, State, Zip): _________________________________________________ HPhone:____________________
WPhone: ___________________________ Extension: _______ Cell Phone: ____________________________
If there are other emergency contact numbers, please write them on the back of this form.
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PASSPORT INFORMATION: to go to Australia you will need a Visa (ETA) to enter the country. Your Travel Source can
run your ETA's for you at no charge. This information is
needed for your ETA.
Surname (Last): ____________________ Given Name (First and middle Name):______________________
Passport #: _________________ Date of Birth: ____________ Sex: ___ Date of Issue: _________ Nationality: ________
Issued Where: __________ Date of Expiration: _____________________ Type of Passport: USA - Other
_____________
-_________________________________________________________________________________ _______________
Surname (Last): ____________________ Given Name (First and middle
Name):______________________
Passport #: _________________ Date of Birth: ____________ Sex: ___ Date of Issue: _________ Nationality: ________
Issued Where: __________ Date of Expiration: _____________________ Type of Passport: USA - Other _____________
Please make sure that you attach the name page of your passports to this form.
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AIRLINE INFORMATION
What airports do you prefer? #1_______________ #2_______________
#3_______________________________
Frequent Flyer Numbers: United (earn miles on Air New Zealand):_____________________________________________
AA (earn miles on Qantas and
Air Tahiti Nui):______________________________________________________________
Would you like us to set up a frequent flyer number for you? Yes
No Having a frequent flyer account is free.
Seat Request: Window q Aisle q Aisle and Aisle q Meal
Requests:_____________________________________
Special Needs (Wheelchair, etc.) _______________________________________________________________________
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HOTEL INFORMATION
What type of hotels do you like to stay in? ________________________________________________________________
Special Requests: Smoking: q Nonsmoking: q Bedding Request: King: q Queen: q Twin: q
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CAR RENTAL INFORMATION
Special Requests: Type of Car: Economy q Compact q Intermediate q Full-size q Specialty q
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TRAVEL INFORMATION
Where have you traveled before?
_______________________________________________________________________
__________________________________________________________________________________ _______________
What type of travel do you
prefer? Cruising q Independent Travel q Escorted Tours q Adventure Travel q
What do you like to do when you are
traveling?_____________________________________________________________
__________________________________________________________________________________ _______________
What areas of Australias
would you like to see and what would you like to experience when you are in Australia: __________________________________________________________________________________
_______________
__________________________________________________________________________________ _______________
__________________________________________________________________________________
_______________
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INTERESTS
What are your interests (please circle):
Wildlife Historical sights Hiking Walking Casinos Museums
Shopping Markets Beaches Snorkeling Diving Surfing
Great Barrier Reef Harbour Cruise Good restaurants
Sightseeing Day Trips The Outback Bridge Climbs Zoos Spas
Aboriginals Aboriginal Art
Trains Markets Bicycling Opals Theatre Cattle Stations Australian Amusement Parks
Ride a Camel Swim or see
dolphins Dinner on a tram Helicopter rides Hot air ballooning Self-drive Wine Cruising Golf
Live Aboards Sailing Kayaking Rafting Farmstays Birding School of the
Air Royal Flying Doctor Service Houseboating
PLEASE LIST ANY OTHER INTERESTS:
_________________________________________________________________
__________________________________________________________________________________ ________________
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BUDGET
Please give us some idea of what type of budget you are looking at for your
trip. We don't set the prices but this gives us some idea
what will work for you. $_____________________________________
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TRAVEL INSURANCEI
n order to protect your investment plus
protect yourself and your family while you are traveling it is recommended that you seriously consider buying travel insurance. To learn more about travel insurance, please go to our website
at
http://www.yourtravelsource.com and click on Travel Insurance. Or call (800) 597-0594 for more information. The tour
company also offers travel insurance and their prices can be provided for you.
q I would like to purchase travel insurance q I choose not to purchase travel insurance q Please call me to discuss this.
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FOREIGN CURRENCY
Your
Travel Source can sell you foreign currency through American Express. Check here if you would be interested in buying
currency before you leave on your trip.
q I would like to purchase travel insurance q I choose not to purchase travel insurance q Please call me to discuss this.
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DOCUMENTS
Please give us an address to send your documents. Your work place is preferred. Documents are sent out via DHL
Send to: Company
Name:____________________________________________________________________________
Address: ____________________________ City: ______________________ State: ______ Zip:
________________
Contact Name: _________________________________________________ Phone #: __________________________
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CREDIT CARD INFORMATION:
Type of Credit Card: MC VI DI AX #: _______________________________________ VID: (3 digits) ___________
Expiration Date: _________________ Your name as it appears on your credit card: ___________________________________
Your billing address & phone number:
______________________________________________________________________
Address
City State
Zip Phone #:
Please fill out this form and include a copy of the name page of your passport(s) - the page
that includes your fullname
and expiration date and send to Your Travel Source. Before sending, please read the Travel Consumer Restitution
Corporation Disclosures below and make
sure you check the line below.
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q I have read and understand the TCRC Disclosures below.
TRAVEL CONSUMER RESTITUTION CORPORATION (TCRC) DISCLOSURES
Your Travel Source is a participant in the Travel Consumers Restitution Corporation (TCRC). Registration as a
seller of travel does not constitute approval by the State of California. California law requires certain sellers of travel to have a trust account or bond. This business has a trust
account. Our CST# is: 2037874-40.
Right of California Customer to Make Claim on the California Restitution Fund
All payments for transportation or travel service not provided to the passenger shall be promptly refunded, in
accordance with the agreed-to-terms and conditions, unless the passenger otherwise instructs the seller of travel in writing.
You, the passsenger, may request reimbursement from TCRC if you are owed a refund of more than $50 for
transportation or travel services which was not refunded in a timely manner by a seller of travel who was registered and participating in the TCRC at the time of sale. The maximum amount
which may be paid by the TCRC to any one passenger is the total amount paid on behalf of the passenger to the seller of travel, not to exceed $15,000.
A claim must be submitted to the TCRC within six months after the scheduled completion date of the travel. A
claim must include sufficient information and documentation to prove your claim and a $35 processing fee. You must agree to waive your right to other civil remedies against a registered
participating seller of travel for matters arising out of a sale for which you file a claim with the TCRC, if you were located in California at the time of the sale. You may request a
claim form by writing to : Travel Consumer Restitution Corporation, P.O. Box 6001, Larkspur, CA 94977-600l; or by faxing a request to: (415) 927-7698.
Customers Located Outside of California
This transaction is not covered by the California Travel Consumer Restitution
Fund. You are not eligible to file a claim against that Fund in the event of this Travel Agency's default.
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