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CLIENT PROFILE FORM
Please complete this form to provide us with the information we will need to book your trip.
PLEASE COMPLETE ONE FORM FOR EACH ADULT (18+) IN YOUR TRAVEL PARTY
TRAVELER INFORMATION
Secure Flight Program: As of May 15, 2009, the U.S. Department of Homeland Security has implemented the Secure Flight Program. All reservations must include the traveler's first name, middle name, last name, date of birth and gender as it appears on their identification used for check-in.
SPECIAL NOTE: If you have any legal issues that would prevent you from traveling outside of the US, it is your responsibility to verify your ability to travel. Great Escapes Travel, LLC will not be responsible for any denied boarding or entry due to legal matters.
*Required
Name
*
Prefix
First
Middle
Last
Suffix
Provide your name as it appears on your Government Issued photo ID (ex. Passport or Driver's License).
NOTE: If the name on your ticket does not match the name on your Government issued ID, you may be denied boarding.
Include the Prefix (ex. Dr., Rev., Mr., Miss, Ms., Mrs.)
Include the Suffix (ex. Jr., Sr., II, III) if applicable
Birth Date
*
MM
/
DD
/
YYYY
Gender
*
Please select
Female
Male
Citizenship
*
US
Canada
Other
Citizenship (Other)
List the name of the Country where you have Citizenship.
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Preferred Email
*
Secondary Email
If the Preferred email you provided is a Work email, please provide an alternate email address that can be used to contact you in case you don't have access to your Work email address
Home Phone
*
###
-
###
-
####
Cell Phone
*
###
-
###
-
####
Work Phone
###
-
###
-
####
Ext.
###
Traveling With/Roommate
*
Prefix
First
Middle
Last
Suffix
Please provide the name of the person/people you are traveling with.
If you are traveling with Minors (17 years old and younger), enter their information in the "Traveling with Minors" section of the form.
If you are traveling with more than one adult, list the other names in the Additional Information section below.
If you are traveling by yourself type "N/A" in the First and Last name fields
SPECIAL ACCOMMODATIONS
Please provide information regarding any special accommodations you may need
I use the following equipment:
Check all that apply:
*
Wheelchair
Scooter
Oxygen
Crutches
CPAP machine
I am on Dialysis
None
I will need to rent following equipment during my trip:
Check all that apply:
*
Wheelchair
Scooter
Refrigerator (for baby supplies or for medical reasons)
None
Dietary Restrictions
*
Diabetic
Gluten Free
Kosher
Pescatarian
Vegan
Vegetarian
Food Allergies
None
List the foods you are allergic to:
EMERGENCY CONTACT INFORMATION
Please provide contact information for someone who is NOT traveling with you
Emergency Contact Name
*
Provide the name of someone who is NOT traveling with you.
Emergency Contact Phone
*
###
-
###
-
####
Provide the phone number of someone who is NOT traveling with you.
Emergency Contact Relationship
*
PASSPORT INFORMATION
All U.S. citizens traveling outside the United States by air must have a valid U.S. Passport Booklet.
A Passport Booklet is considered to be valid when:
The Passport Booklet's expiration date is at least 6 months past your trip return date.
The Passport Booklet has two or more blank pages.
The Passport Booklet is in good condition - no creases, folds, tears, stains or missing pages.
Travelers are responsible for meeting ALL document requirements for travel. For complete regulations regarding Passport requirements, visit https://travel.state.gov/content/travel/en/passports.html.
A Passport Booklet is not required for traveling outside the United States by land or sea, however it is strongly recommended that you travel with one.
A Passport Booklet is not required for U.S. citizens traveling to U.S. territories such as Puerto Rico and the U.S. Virgin Islands.
Passport Status
*
I have a valid Passport Booklet.
I have applied for a Passport Booklet (new or renewal)
I do not have a Passport Booklet (see Note #1 below)
Passport Name
First
Middle
Last
Suffix
List your name EXACTLY as it appears on your Passport
Passport Number
Passport Country of Issue
Passport Expiration Date
MM
/
DD
/
YYYY
Please take a picture of your Government issued photo ID (for domestic trips) or your Passport photo PAGE (for international trips) and upload it here.
If you have applied for your Passport or ar renewing it, please attach a copy of the Passport application.
You can also send it by email to angela@greatescapesta.com
For Passports, send a picture of the entire Passport photo page and not just a picture of your Passport photo
NOTE #1 >>>
I acknowledge that I have read this statement
*
ALERT: A valid Passport Booklet is required for all U.S. citizens (including children) exiting and re-entering the United States by air. No other documentation will be accepted for re-entry into the United States when traveling by air.
The Passport expiration date should be at least 6 months past your trip return date.
The Passport should have two or more blank pages, or some countries may not let you enter.
The Passport must be in good condition - no creases, folds, tears, stains or missing pages.
Travelers are responsible for meeting ALL document requirements for travel. For complete regulations regarding Passport requirements, visit https://travel.state.gov/content/travel/en/passports.html.
NOTE: A Passport Card is accepted when entering the U.S. by land (driving) or by sea (a cruise).
NOTE #2>>>
I acknowledge that I have read this statement
*
If you have any legal issues (including arrests, charges and/or convictions) that might prevent you from traveling outside of the United States, it is YOUR responsibility to verify your ability to travel.
Great Escapes Travel, LLC will not be responsible for any denied boarding or entry due to legal matters. If you have any questions about your ability to travel or obtain a US passport, you should consult a legal professional as well as the passport rules of all the countries applicable to your travel.
TRAVELING WITH MINORS
If you are traveling with children (under the age of 18), please provide the following information for them in this section
Child #1
List the following information:
*Full Name (EXACTLY as it appears on birth certificate or Passport)
*Birth Date
*Passport Number
*Passport Expiration Date
Child #2
List the following information:
*Full Name (EXACTLY as it appears on birth certificate or Passport)
*Birth Date
*Passport Number
*Passport Expiration Date
Child #3
List the following information:
*Full Name (EXACTLY as it appears on birth certificate or Passport)
*Birth Date
*Passport Number
*Passport Expiration Date
Child #4
List the following information:
*Full Name (EXACTLY as it appears on birth certificate or Passport)
*Birth Date
*Passport Number
*Passport Expiration Date
TRAVEL PREFERENCES
For each category, list your preferences (in order) as well as your Membership ID #s
AIRLINES
Use this section to provide information about your Airline preferences.
Airport
*
List the City where the airport you travel from is located
Airline
If you do not have a Preferred Airline, you can leave this section blank.
Frequent Flyer #
Airline
If you do not have a Preferred Airline, you can leave this section blank.
Frequent Flyer #
Seating
(Select all that apply)
Aisle
First Class
Middle
Business Class
Window
Exit Row
Bulkhead
Redress #
A unique TSA-issued number that helps the TSA eliminate watch list misidentification and verify your identity
Known Traveler #
(KTN)
A unique TSA, Global Entry, NEXUS or SENTRI issued number that helps expedite the security process at the airport
CRUISES
Use this section to provide information about your Cruise Line preferences. If you do not have a Preferred Cruise Line, you can leave this section blank.
Cruise Line
Membership ID #
Cruise Line
Membership ID #
Cruise Line
Membership ID #
Preferred Cabin Type and Location
(Select all that apply)
Suite
Forward
Balcony/Verandah
Mid Ship
Ocean View
Aft
Inside
Upper Deck
Cabin Type (if not listed above)
Type in the name of the specific Cabin category you would like to book.
HOTELS
Use this section to provide information about your Hotel preferences. If you do not have a Preferred Hotel, you can leave this section blank.
Hotel
Membership ID #
Hotel
Membership ID#
Hotel
Membership ID #
Preferred Room Type
(Select all that apply)
Suite
Smoking
King
Non Smoking
Queen
Near Elevator
Double
High Floor
Room Type (if not listed above)
Type in the name of the specific room category you would like to book.
CAR RENTAL
Use this section to provide information about your Car Rental preferences. If you do not have a Preferred Car Rental company, you can leave this section blank.
Rental Car
Company
Membership ID #
Rental Car
Company
Membership ID #
Car Type
(Select all that apply)
Economy
Compact
Mid Size
Full Size
Premium
Luxury
Minivan
Mid Size SUV
SUV
7 Passenger Van
15 Pass. Van
Add Ons
GPS
Car Seat
Booster Seat
Insurance
Additional Information
Please provide any additional information that we should be aware of regarding your Travel preferences
Add me to the mailing list
*
Please select
Yes
No
Escape Artist
*
Please select
Angela Barr
Select the Travel Agent you are working with
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