Name*

Middle name

Last name*

Date of birth (dd/mm/yyyy)*

E-mail address*

Cell phone

Home Airport

Mailing address

Work Information

Company name

E-mail address

Business phone

Fax number

Passport

Country of Issue*

Please select... Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Ceuta and Melilla Chad Chile China Christmas Island Clipperton Island Cocos [Keeling] Islands Colombia Comoros Congo [DRC] Congo [Republic] Cook Islands Costa Rica Côte d’Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Diego Garcia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands [Islas Malvinas] Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia [FYROM] Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar [Burma] Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands North Korea Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino São Tomé and Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Outlying Islands U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

Date of Issue*

FULL NAME NEEDS TO BE AS SHOWN ON PASSPORT

First name*

Middle name

Last name*

Nationality*

Passport Number*

Valid Until*

Visas

Country

Expiration date

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Driver’s License

Driver’s License number

Valid Until

Frequent Flyer Programs

Program name / Status

Please select... Air Europa- Flying Blue AirTran Airways - A+ Rewards Alaska Airlines - Mileage Plan American Airlines - AAdvantage Avianca - AviancaTaca LifeMiles British Airways- Executive Club Continental Airlines - OnePass (merged into United MileagePlus) Copa Airlines - OnePass (merged into United MileagePlus) Delta Air Lines – SkyMiles Frontier Airlines - EarlyReturns Iberia- Iberiaplus Hawaiian Airlines - HawaiianMiles JetBlue Airways - TrueBlue LAN Airlines - LANPASS Southwest Airlines - Rapid Rewards Spirit Airlines - FREE SPIRIT TACA Airlines - AviancaTaca LifeMiles) TAM Airlines - MileagePlus United Airlines- Mileage Plus US Airways - Dividend Miles Virgin America - eleVAte Virgin Atlantic – Flying Club Other

Account number

Airplane Preferences

Preferred Class:

economy    business    first

Position:

aisle    window    center

Hotel Programs

Hotel name

Please select... Hilton Honors Hyatt Gold Passport Marriott Rewards Priority Club Rewards Starwood Preferred Guest OTHER

Guest number

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Hotel Preferences

Stars:

3 stars    4 stars    5 stars

Type:

suite    king    double

Rental Car Programs

Car Company name

Account number

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Rental Car Preferences

Type

Please select... Economic Mid-Size Standard SUV

Special requests

We will always request your travel preferences, however they cannot be guaranteed.

Credit Card Information

Please call us at +1 (305) 532-6999 to provide us with the details of your credit card.

*ALL FIELDS MARKED WITH AN ASTERISK ARE REQUIRED TO ISSUE TICKETS PER NEW TSA REGULATIONS AS OF 15 SEP 2010.