EmailMe Form - Client Qualification Form (Land)

Todays Date *

MM / DD / YYYY

Primary Passenger *

Prefix First Middle Last Suffix

Phone Number *

### - ### - ####

Address *

Street Address City State / Province / Region Postal / Zip Code

Date of Birth *

MM / DD / YYYY

Do you have a passport *

Yes

No

Passport Number

Passport Expiration Date

MM / DD / YYYY

Citizenship *

When are you planning on traveling *

Destination Interested In *

Number of Adults *

Number of Children

Email *

Additional Passenger Information

Prefix First Middle Last

Date of Birth

MM / DD / YYYY

Address if different from primary passenger

Street Address City State / Province / Region Postal / Zip Code

Anniversary Date

MM / DD / YYYY

Do you have a passport

Yes

No

Passport Number

Passport Expiration Date

MM / DD / YYYY

Citizenship

Additional Passengers
Name/Sex/Address/ Date of Birth/Passport Information/Citizenship

Room Type Request/ Land

Specific airport to depart from? *

Type of Vactation *

Budget Per Person *

Length of Travel *

What activities do you enjoy? Where have you traveled to?

Special Needs (Health Issues, Diet Restrictions, Walking Issues).

What is on your bucket list?

Travel Insurance *

Yes

No

As professional travel agent I feel that it is my responsibility to recommend travel insurance to protect your investment. Please read the travel insurance information that I emailed to you carefully in order to make an informed decision concerning this important matter. Ask
us or call us with any questions you may have. Travel insurance must be purchased at time of first payment.
I have been advised of the cancellation penalties for my purchase. I acknowledge receipt of the
Travel Insurance and understand that
I understand that Travel Insurance can protect me from possible loss of money due to supplier
bankruptcy/default, unexpected trip cancellation/interruption due to accident, sickness or death,
baggage loss, medical expenses, and emergency air transportation costs.
I understand that I must purchase Travel Insurance immediately to obtain maximum coverage.

Agreement By typing your name and date in the below space. I have provided the accurate spellings of names, dates of birth for myself and other travelers. I acknowledge that it is my responsibility to confirm the accuracy of these passenger details when the final booking is completed and to notify Trippin with Crystal's Travel of any corrections promptly. *

Date Time *

MM / DD / YYYY