Phone: (417) 451-5468 | Email:

Zimmer Radio - 2019 Winter Cruise Breakaway

RESERVATION FORM

 

Passenger Name(s)                                                            Date of Birth        Gender                        Daytime Telephone

(Name spelling should match your passport spelling or Driver’s License)

 1._______________________________________         _____________    _________                _____________________

 2._______________________________________         _____________    _________                _____________________

 Mailing Address: _______________________________________________________________________________________

 Home Phone: ______________________Work Phone: _____________________ Cell Phone: ______________________

 Email Address: _______________________________________________ Home or Work

 Cruise Room Requested __________________________________ (Inside, Ocean, Balcony, Concierge, or Aqua)

 Are you sharing your room with anyone not listed above?

 What is their Name(s)____________________________________________________­­­­­­­­_________________

 Cruise Dinner Time Choice (circle one):                      Freestyle (you choose time)                              7:30pm with Group

 

Travel Insurance (Yes or No)   ________________

Amount Enclosed:        Cruise Deposit ($500 per person)       ________________

                                                                  Insurance Cost       ________________

                                                                  Total Enclosed        ________________

 Please make checks payable to GalaxSea Cruises & Tours.

 OR WE CAN CHARGE TO YOUR CREDIT CARD:

 Credit Card Number: ___________________________________________ Sec Code ___________ Expiration ___________________

 Name on Card: _________________________________________     Signature: ___________________________________________

 Credit Card Billing Address:

 ____________________________________________________________________________________________________________

 SPECIAL NEEDS/REQUESTS

 __________________________________________________________________________________________

 __________________________________________________________________________________________

 __________________________________________________________________________________________

 COMPLETE AND MAIL WITH DEPOSIT TO:

GalaxSea Cruises & Tours, 210 N. Business 49, Neosho, MO 64850

Email to info@galaxseaonline.com; Or Fax to 417-451-9120