Travel Request Form

Home Base MGB Profile and Travel Request Form

Home Base Invitee Travelers
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 Mobile Phone Number *
Area code and number
Business Email*
example@example.com
Are you traveleing internationally?

YesNo
- PASSPORT INFORMATION
  For International Travel Only: For US Citizens passports must be valid for at least six months from expected return date to United States and have 2 blank pages not including the back two pages. For citizens of other countries please obtain the information from Embassy of any countries you plan to travel or connect through. Visa's and COVID-19 travel requirements are the responsibility of the traveler.
- Passport Number
- Passport Issuing Country
- Passport Expiry Date
- Nationality
- Would you like a travel profile set up for future travel?*
  
  YesNo
- Would you like to receive our vacation specials?
  
  YesNo
- 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 (as it appears on your Passport or Government Issued ID)*
  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
- Do you have Frequent Flyer, Hotel, Car Membership Numbers?
  
  YesNo
- Membership AAA (For hotel savings, may need to present card at check in-if you have an AAA fare)
  
  Yes
- 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?
  
  YesNo
- 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
  Date
- Return Date*
  
  MonthDayYear
  Date
- Preferred Departure Time
  
  :HourMinutesAM/PM Option
- Preferred Return Time
  
  :HourMinutesAM/PM Option
- Seating Preference*
  
  Aisle SeatWindow SeatNo preference
- 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
  
  More-Leg Room SeatingUpgrade to Business ClassUpgrade to First ClassWould like to know the options on a trip by trip basis
- Do you need multiple destinations?
  
  YesNo
- Multi-Destinations
  *Indicate what destinations you need.
- Other Flight Details
- Do you require accommodations?
  
  YesNo
- Number of Rooms
  *Please list the number of rooms needed for your reservation.
- Room/Bedding Type
  *Please select which bed/room type you prefer.
- 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?
  
  YesNo
- Preferred Car Rental
  *If you have a preferred car brand, please list here.
- Do you require train/rail?
  
  YesNo
- 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?
  
  YesNo
- 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
  
  Clear
- Click the Box*
- Should be Empty:

Home Base MGB Profile and Travel Request Form

Business Unit and Cost Center