It's Vacation Planning Time!!!

It's Vacation Planning Time!!!

The information obtained will be used for your upcoming vacation.
Name (as it appears on your card) *

First Name Last Name Suffix
Address (as it appears on your account) *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Trip information (i.e. dates, name of event, etc.) *
Names (as it appears on your passport) and DOB (If you are paying for more than one person, put complete info for each person) *
Total amount of vacation *
Your cost - Greater than $1
Last 4 digits *
You will be contacted for additional information
Exp. Date *
Enter as MMYY
DL number and exp date *
Do you authorize this card to be used for all payments unless otherwise specified in writing to LOT's Travel Affair? *

Yes No
Would you like travel insurance? *

Yes No (Client understands that declining travel insurance could result in the loss of travel cost and/or require more money to correct the situation. Client also acknowledges that without insurance, there will be no way to recoup any losses, costs, or expenses incurred.)
If you cancel for any reason there will be a $150.00 cancellation fee per person charged by LOT's Travel Affair in addition to any other possible fees charged by the vendor. The cancellation fee will be charged to the card on file unless other arrangements are made prior to the cancellation. This fee has to be paid before the cancellation is processed with the vendor.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty: