EmailMe Form - Individual Reservation

Name *

First Last

Email

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone Number

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

Skype name:

If you are deaf and do not have VP and are from other countries out of USA, you can give us your Skype name where we can contact you.

Cell Phone Text Number

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

for Texting Purpose.

Emergency Contact Name:

First Last

How are you related to this emergency contact name?

Parents, Grandparents, Sister, Friend, etc.

Emergency Contact Phone Number:

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

Your Birthdate: *

MM / DD / YYYY

Are you?

Deaf

Hard of Hearing

Hearing

Bed Configuration?

Twin Beds Converted into Queen Bed (together)

Separate Twin Beds

Dining Time Choice (not guaranteed)

1st Dining Time

2nd Dining Time

Anytime Dining

First Dining time tends to be at about 5:30-6 PM, Second Dining time tends to be at about 8-8:30PM. Anytime Dining dining tends to be between 5:30 - 9PM (wait in line).

Guest Name 2:

First Last

Guest 2 Email:

Guest 2 Birthdate:

MM / DD / YYYY

Guest 2:

Deaf

Hard of Hearing

Hearing

Guest Name 3:

First Last

Guest 3 Email:

Guest 3 Birthdate:

MM / DD / YYYY

Guest 3:

Deaf

Hard of Hearing

Hearing

Guest Name 4:

First Last

Guest 4 Email:

Guest 4 Birthdate:

MM / DD / YYYY

Guest 4:

Deaf

Hard of Hearing

Hearing

Disability or Special Needs for any guests in this stateroom?

Wheelchair, diabetes, or any special needs (the cruise line might be able to help)?

Choose if any of you are:

Age 55+

An Active duty or retired U.S. Military or Canadian Forces

An Active duty or retired member of local or state/province Law Enforcement, Fire Dept. or EMT

AARP Member

Sometimes you might qualify for discounts.

Which Cruise Lines have any of you been on before?

Do you want to pay monthly (at least $50 a month)?
We Strongly encourage you to pay monthly so you do not get a big bill at final payment. All charges for deposits and monthly payment go directly to cruise lines and you will get invoices from the cruise line. We never touch your money as it is for your and our protection.

No.

Yes. I will call each time (varies on dates and amounts).

Yes. Choose Date you want to pay the same day each month.

Date you want to start paying each month?

MM / DD / YYYY

How much do you want to pay each month? (f you desire)

Credit/Debit Card or Personal/Business Check

This will not charge to your card automatically. It will be done manually on cruise line portal. We usually do it within 24 hours. You will be charged for your deposit. If you are writing a check, write it to: Best Price Break, Inc. Mail it to:

Best Price Break, Inc.
640 Woods Drive
Lehi, Utah 84043

Amount to be charged to your card (US Dollars)

$ Dollars . Cents

If you do not know, put in 0.00 and then we can let you know.

Credit/Debit Type or Personal/Business Check

We strongly recommend you to use credit/debit card. Writing a check can delay and maybe miss a deadline.

Credit/Debit Card Number

15 Numbers for American Express and 16 Numbers for Visa, MasterCard, and Discover.

Expiration Date (MM/YY)

CVV: 3 Numbers on back of your card for Visa, Mastercard or Discovery. If it is American Express, it is 4 number on front right side of the card.

Leave any none (if desired)