Travel Abroad Registration

Agent Name: Elise Redman

Contact Information:

Full Name*

First NameLast Name

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

Cell Phone Number*

Area CodePhone Number

E-mail*

Emergency Contact Name*

First NameLast NameRelationship

Emergency Contact Phone*

Area CodePhone Number

Date of Departure*

MonthDayYear

Date of Return*

MonthDayYear

Passenger Names & Information: (Please List Full Legal Names)

Passenger 1*

First NameMiddle NameLast Name

Suffix (If noted on your official Government issued Passport or Identification)

Birth Date*

MonthDayYear

Gender*

Passenger 2

First NameMiddle NameLast Name

Suffix (If noted on your official Government Issued Passport or Identification)

Birth Date

MonthDayYear

Gender

Passenger 3

First NameMiddle NameLast Name

Suffix (If noted on your official Government Issued Passport or Identification)

Birth Date

MonthDayYear

Gender

Passenger 4

PrefixFirst NameMiddle NameLast Name

Suffix (If noted on your official Government Issued Passport or Identification)

Birth Date

MonthDayYear

Gender

Full names must be listed as they appear on your government issued identification and passport for all travelers. If additional space is needed use the Additional Comments section located at the botton of the form.

All names and dates of birth listed above are as they appear on the respective government issued identification for each named person*

I agree

Travel Insurance:

I have been advised of the option to purchase travel insurance.*

I agree and understand that my investment is at risk if insurance is not purchased.

Passenger 1 Insurance Coverage*

AcceptDecline

Passenger 2 Insurance Coverage (if applicable)

AcceptDecline

Passenger 3 Insurance Coverage (if applicable)

AcceptDecline

Passenger 4 Insurance Coverage (if applicable)

AcceptDecline

Medical/Special Needs (If YES, note in comments section at end of this form in full description)*

Travel Provider and it's third parties has expressly acknowledged that passports and or visas must be provided to travel. I shall indemnify, defend, and hold harmless The Travel Provider and all third party agencies from and against any and all liabilities, claims, losses, lawsuits, judgments, and/or expenses, including attorney fees, arising either directly or indirectly from any act or failure to not possess said document, and any incidents which may occur during or which may arise out of the performance of this Agreement. PLEASE Ensure your passport has a minimum of 6 months validity before active travel outside of the U.S.*

I agree

Passports/Visas:

Passenger 1: Passport Number*

Expiration Date*

MonthDayYear

Passenger 2: Passport Number

Expiration Date

MonthDayYear

Passenger 3: Passport Number

Expiration Date

MonthDayYear

Passenger 4: Passport Number

Expiration Date

MonthDayYear

Add-Ons:

Pricing Subject to Change Based on Availability of Some Items

Quote

Travel Insurance (Call for Rates)

I have been advised of potential change/cancellation charges that are implemented by the Travel Provider and it's suppliers in the event that I choose to cancel or change my booking after making the initial deposit and or full payment.*

I agree

Card Holder Authorization

I, the above-named authorized credit card user, give Travel Provider by Elise Redman (www.thetravelprovider.com) and its representative, authorization to charge my credit card for the purposes detailed within the provided quote, to which pricing cannot be guaranteed and is subject to change unless deposited upon at the specified due date noted within the quote. I understand that this form constitutes a legally binding contract and that by affixing my signature to this form, I am accepting responsibility for all charges which are amicably agreed upon. By signing this form, I acknowledge receipt and full understanding of its contents.

Disclosure and Consent

Prices will not increase after you make deposit payment, except for charges resulting from increases and changes in airfare pricing and it's itineraries and government-imposed taxes, fees or fuel supplement surcharges which suppliers may collect in effect at the time of your trip, even if the trip fare has been paid in full.

By signing below, I agree to the accuracy of the information to which I have disclosed and agree to the full contents within this form. If on Desktop computer utilize your mouse and if on mobile device, iPad or the like, you may use your finger or a stylus touch pen to sign below.

Note: Your card will be charged within 24-48 hours of you completing a Credit Card Authorization Form, separate of this form, for the purpose as authorized above. Once you submit THIS secure Registration Form and arrive to the Thank You page, you will be instructed to click a hyperlink which will confidentially re-direct you to a secure Credit Card Authorization Form.

Signature*

Additional Comments or Passenger Information

Enter the message as it's shown*

Travel Registration

Card Holder Authorization