Phone: (417) 451-5468 | Email:

MERCY NWA - Italian Sampler Vacation

September 13 – 23, 2018

 TRIP RESERVATION FORM

 Legal Name/s (as appears on passport)             Gender             Date of Birth          Daytime Phone

 1.____________________________________      ________          _____________     ___­­­_______________

 2.____________________________________      ________          _____________     __________________

 Mailing Address__________________________________________________________________________

 Home Phone ____________________ Work Phone ___________________ Cell Phone ___________________

 Email___________________________________________________          

 Will you be sharing a room with someone not listed above?  If yes, please give us their name:

 _____________________________________________________________________

 Do you wish to pre-pay your tour gratuities with your final payment:        Yes                  No

 Trip Deposit Enclosed ($600 per person)            ___________________

 Travel Insurance ($269 per person)                     ___________________

                                Total Payment Enclosed     ___________________

Make checks payable to GalaxSea Cruises & Tours

OR we can charge your credit card with the payment listed above:

Credit Card Number ______________________________________Sec Code ________Expiration ____________­____

Name on Card___________________________________ Signature__________________________________________

Credit Card Billing Address__________________________________________________________________________

Special Needs or Requests

_____________________________________________­­__________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

COMPLETE AND MAIL WITH DEPOSIT TO:

GalaxSea Cruises & Tours, 210 N. Business 49

Neosho, MO  64850

Or Fax to 417-451-9120

Contact Ken Mayer – ken@galaxseaonline.com