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Print out this form, fill it out and FAX it to (707) 966-1114
(The form lines-up properly when you set your browser fixed font setting to Courier 10 or Monaco 10)
NOTE: The information requested (where applicapble) is needed that we can better serve your travel requirements. We will be able to have at our fingertips your personal data stored in a computer profile enabling us to meet your needs on a consistent basis and to conserve your valualble time. ALL DATA ARE RETAINED IN STRICT CONFIDENCE.
Confidential Client Record
______________________________________________ _______________________ Name: first initial last Title: _______________________________________________________________________ Company Name: _________________________________________ ____________________________ Department _________________________________________ Business Address: ________________________________________________________________________ Account billing address if different than business: _________________ __________ ________________________________________ Business phone: Ext.: Assistant's name _________________________________________ ____________________________ Home phone: Listed/unlisted _________________________________________ ____________________________ Personal address: Spouse name: _________________________________________ ____________________________ Personal phone credit calling number Children names and ages _________________________________________ ____________________________ Business phone credit calling number _________________________________________ ____________________________ Credit card Info (Business) Exp. date ____________________________ Exact name on card ________________________ _______________________________ ____________ Nationality Passport number Exp. date
Preferential Travel Information ________________________________________________________________________ Airline choices in order of preference _________________________ ________ ___________________________________ Seat selection smoke/no Location in aircraft __________________________________ ___________________________________ Special meal requests Class of service ________________________________________________________________________ Hotel Chains ________________________________________________________________________ ________________________________________________________________________ Hotel credit card or discount no. _______________________ ______________________ _____________________ Type of room Room location Bed type ________________________________________________________________________ Special requirements __________________________ ___________________________ _______________ Rental Car Company Car type Auto/Stad.Trans. ________________________________________________________________________ __________________________ ____________________________________________ Corporate discount no. Express checkin ________________________________________________________________________ ________________________________________________________________________ Additional comments (please use the back of the form for additional information if needed) NOTE: Sign this form if you want to authorize Town & Country Travel
to sign your credit card charges by means of a "Phone Charge." _________________________________________ _____________ Signature Date Please FAX this form to (707) 966-1114