EmailMe Form - Miranda & Thomas Room Reservation Form

Contact:

First Last

Phone *

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

Email *

email@email.com

Traveler 1 *

First Middle Last

Date of Birth

MM / DD / YYYY

Airline Loyalty #

TSA pre-check #

Passport?

Yes

No

Traveler 2

First Middle Last

Date of Birth

MM / DD / YYYY

Airline Loyalty #

TSA pre-check #

Passport?

Yes

No

Traveler 3

First Middle Last

Date of Birth

MM / DD / YYYY

Airline Loyalty #

TSA pre-check #

Passport?

Yes

No

Traveler 4

First Middle Last

Date of Birth

MM / DD / YYYY

Airline Loyalty #

TSA pre-check #

Passport?

Yes

No

Land Only or With Airfare?

Land Only

Please provide quote for Flights

If flights, from what city:

# of Nights ?

Departure Date ?

Barcelo Maya Palace

Jr Suite Garden View

Jr Suite Pool View Premium Level

Jr Suite Ocean Front Premium Level

Trip Insurance Notification: Trip insurance is strongly recommended to protect you from certain situations that could cause this trip to be cancelled, interrupted, and/or delayed resulting in a loss of time and money. Insurance paid with deposit. Please choose one: *

I choose not to protect my investment with trip insurance. I understand that the Simply Travel will be held free of any claims made as part of this transaction.

Please provide quote for trip insurance - provided by TripMate. Questions should be directed to Insurance provider 1-866-389-5378. Details found here https://www.tripmate.com/wpGR430/

Cardholder's Name

First Last

Name as it appears on card

Credit Card

Billing Address *

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

I am the owner of this credit card and I agree to pay the deposit amount due. I agree not to dispute this charge with my credit card company. Please initial below *

Additional comments

Signature (sign with mouse, stylus, or finger) *

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Today's Date *

MM / DD / YYYY