Travel Request Form

MGB Profile and Travel Request Form

Traveler must provide a MGB affiliated email address
Business Unit and Cost Center

Billing Information
MGB Affiliations/Hospital
Department Name
Billing Business Unit
4 digit number
Cost Center/Fund Number
6 characters
TRAVELER INFORMATION

The following information is required for TSA compliance, Great Getaways internal records, reservation ticketing, and MGB Risk Management.
Traveler Legal Last Name
Last Name
Traveler Legal First and Middle Name
First and Middle Name
Traveler Passport Last Name
As it appears on your passport if different from above
Traveler Passport First/Middle Name
As it appears on your passport if different from above
Traveler Legal Name

Last Name Middle NameFirst Middle
Traveler Legal Name (as it appears on your passport if different from above )

Last NameFirst Middle
Last Name* / First Name* Middle
Traveler Mobile Phone Number

Area CodePhone Number
Traveler Mobile Phone Number
Area code and number
Business Email
example@example.com
Are you traveleing internationally?
- Passport Last Name / First Name Middle Name
- Passport Document Number
- Passport Issuing Country
- Passport Expiry Date
- Nationality
- Would you like a travel profile set up for future travel?
- Would you like to receive our vacation specials?
- Please provide a personal email address :
  example@example.com
- If you would like to receive our travel magazine please provide your home address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Birth Date
  
  MonthDayYear
- Gender
  Gender must match Government ID
- TSA Pre✔ Known Traveler Number (KTN) GOES
- Redress Control Number (redress number)
- Travel Arranger Name (if different from traveler)
  
  First NameLast Name
- Travel Arranger Email
  example@example.com
- Arranger Phone Number
  Area code and number
- Arranger Phone Number
  
  Area CodePhone Number
- Do you have Frequent Flyer, Hotel, Car Membership Numbers?
- Membership AAA (For hotel savings, may need to present card at check in-if you have an AAA fare)
- FREQUENT FLYER NUMBERS
- American Airlines
  *If you have a frequent flyer account, please list here.
- Delta Airlines
  *If you have a frequent flyer account, please list here.
- JetBlue
  *If you have a frequent flyer account, please list here.
- United Airlines
  *If you have a frequent flyer account, please list here.
- Southwest Airlines
  *If you have a frequent flyer account, please list here.
- British Airways
  *If you have a frequent flyer account, please list here.
- Frequent Flyer other
  *If you have a frequent flyer account, please list here.
- Frequent Flyer other
  *If you have a frequent flyer account, please list here.
- HOTEL MEMBERSHIP NUMBERS
- Marriott Bonvoy
- Hilton
- Hyatt
- Priority Club
- Hotel
- Hotel
- CAR RENTAL MEMBERSHIP NUMBERS
- Hertz Membership
- Enterprise Membership
- Other Car Rental Membership
- Do you have a Travel Request?
- Departure City
  *Please list City & State or Airport you prefer.
- Arrival City
  *Please list City and/or country you want to visit.
- Departure Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Preferred Departure Time
  
  :HourMinutesAM/PM Option
- Return Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Preferred Return Time
  
  :HourMinutesAM/PM Option
- Seating Preference (not guaranteed)
- Accessibility, special needs requirements, air and hotel preferences, and requests?
  *Please list any special needs requests or preferences
- Seating Upgrade - cannot be billed to MGB unless authorized
- Do you need multiple destinations?
- Multi-Destinations
  *Indicate what destinations you need.
- Other Flight Details
- Do you require accommodations?
- Number of Rooms
  *Please list the number of rooms needed for your reservation
- Room/Bedding Type
  *Please select which bed/room type you prefer.
- Corrupt Number of Rooms
  *Please list the number of rooms needed for your reservation.
- Preferred Hotel Brand
  *If you have a preferred hotel brand, please list here.
- Special Requests
  *Please list any special requests you may have.
- Do you require a car rental?
- Preferred Car Rental
  *If you have a preferred car brand, please list here.
- Do you require train/rail?
- Preferred Train Car Class
  *If you have a preferred car class, please list here.
- Anything else you'd like us to know?
  *Please indicate any other travel needs, details, health concerns or special requests for this trip.
- Is there a companion traveler?
- Companion Traveler Name (as it appears on your Passport or Government Issued ID)
  
  Last NameFirst Name/Middle
- Birth Date
  
  MonthDayYear
- Companion Gender (as it appears on your Passport or Government Issued ID)
- Companion Traveler Phone Number
  
  Area CodePhone Number
- Companion Email
  example@example.com
- Companion GOES/TSA Pre-Check/Known Traveler Number
- Frequent Flyer Numbers
  *Please indicate Preferred Airlines followed by your FF number, in order of preference
- Companion Special Needs/requests
  *Please list any special needs requests or air or car preferences
- Signature
- Click the Box
- Should be Empty:

MGB Profile and Travel Request Form

Business Unit and Cost Center