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CONCIERGE CRUISES RESERVATION FORM
Ship: ___________________________
Sailing Date: _____________________
**IN ORDER TO ACCURATELY BOOK ROOMS - PLEASE INDICATE ON THIS FORM THE LEGAL
NAMES OF THE PERSON(S) WITH WHOM YOU WILL BE SHARING A ROOM EVEN IF
YOU ARE NOT FINANCIALLY RESPONSIBLE FOR THEIR RESERVATION**
PLEASE PRINT YOUR INFORMATION
NAMES MUST BE FULL LEGAL NAMES
[1] FIRST NAME: _____________________________MIDDLE NAME: ________________________
LAST NAME: _________________________________DATE OF BIRTH: ______________________
[2] FIRST NAME: _____________________________MIDDLE NAME: ________________________
LAST NAME: _________________________________DATE OF BIRTH: ______________________
[3] FIRST NAME: _____________________________MIDDLE NAME: ________________________
LAST NAME: _________________________________DATE OF BIRTH: ______________________
[4] FIRST NAME: _____________________________MIDDLE NAME: ________________________
LAST NAME: _________________________________DATE OF BIRTH: ______________________
STREET ADDRESS: __________________________________________________________________
CITY: __________________________ STATE: _______________ZIP CODE: ___________________
HOME PHONE: ______________________________ CELL PHONE: _________________________
EMAIL ADDRESS: WORK: _________________________ HOME: __________________________
SPECIAL OCCASION: __________________________ SPECIAL NEEDS: _____________________
DEPOSIT AMOUNT: _________________SELF PAY-CHECK #: _____________________________
NAME___________________________CREDIT CARD #______________________________________
CREDIT CARD: V___MC____AM__ OTHER_____EXP___________________________
ADDRESS FOR CEDIT CARD: __________________________________________________________
CHECK#______________________________________CASH___________________________________
US CITIZEN____________ GREEN CARD____________PASSPORT___________________________
PASSPORT NUMBERS:
PASSENGER: ___________________________________ EXPIRATION DATE: _____________________
PASSENGER: ___________________________________ EXPIRATION DATE: _____________________
HOW MANY ROOMS: __________TYPE OF ROOM -Interior, Ocean View, Balcony________________
INSURANCE (Please Circle One): YES or NO (HIGHLY RECOMMEND INSURANCE)
QUOTE FOR INSURANCE: _________________________________________________________
IF INSURANCE IS DECLINED MUST SIGN: SIGNATURE_____________________________________
**TRAVEL INSURANCE ADVISORY: Travel Insurance Is Strongly Recommended For Protection Against
Losses Occurring From, But Not Limited To, Cancellation Of Trip Due To Illness Or Incapacity; Interruption
Of Trip Due To Medical Or Family Emergencies; Operator Default Or Insolvency; Operator Fees Or Penalties
For Charges Or Cancellations Imposed By Operator, Its Agent Or Affiliated Companies; And Baggage Loss Or
Damage. For Specific Coverage Details Contact Your Insurance Agent Or The Insurance Agent On The
Insurance Carrier Policy Statement. If You Decide Not To Purchase Insurance A Wavier Must Be Signed. **
PLEASE NOTE: IF TRAVELING WITH ORGINAL BIRTH CERTIFICATE: (RAISED SEAL)
MUST BE US CITIZEN) IF YOUR ARE MARRIED YOU MUST HAVE A COPY OF MARRIAGE
LICENSE & DRIVER”S LICENSE TO MATCH YOUR LEGAL NAME.
IF YOU HAVE ANY QUESTIONS, PLEASE CONTACT YOUR TRAVEL AGENT:
CONCIERGE CRUISES/ GEORGENE TRAVEL AGENT / OWNER
RETURN FORM TO: Concierge Cruises
Telephone: (239)-772-1840
Fax Form: (239) 772-4826
Email: [email protected]
Website: http://www.conciergecruises.biz
Authorization For Automatic Payment Plan
I, The Undersigned To Hereby Authorize Concierge Cruises To Deduct $__________ (Amount Of Payment) From My Credit Card On The _____ (Day). This Payment Will Be Charged _____________ (Weekly, Bi Weekly, Monthly) Until The Sum Of $ _______________ (Balance To Be Paid) Is Paid In Full. Payment Arrangement Details For The Balance Must Be Made By Contacting Concierge Cruises. Deductions Are Subject To Change Depending On Taxes, Fees & Additional Add-Ons. Travel Guard Insurance Available Upon Request. If Declined A Wavier Must Be Sign. If Any Changes Occur You Will Be Notified In Writing. Please Provide An Accurate Email Address. I Authorize Deduction Of The Above Amount Unless I Provide Written Cancellations To Concierge Cruises At Least 75 Business Days Prior To The Cruise. I Understand That I May Cancel At Any Time But Financially Responsible For The Cruise Remains Solely With Me & I Will Be Responsible For Full Payment. Cruises May Have Their Own Cancellation Guidelines Which Must Be Adhered To. Please Be Sure To Read, Sign & Return This To Concierge Cruises. Thank You. Printed Name: _____________________________________________________ Signature: _________________________________________________________ Email Address: _____________________________________________________ Date:_____________________________________________________________
