Phone: (417) 451-5468 | Email:

Zimmer Radio - 2019 Alaska Cruise Package

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?

_____________________________________­­­­­­­­_________________

Cruise Dinner Time Choice (circle one):                      Freestyle                                 8:00pm with Group 

Cruise Perk Choice __________________________

Travel Insurance (Yes or No)   ________________

Amount Enclosed:        Cruise Deposit ($400 per person)       ________________

                                                                         Insurance        ________________

                                                                 Total Enclosed        ________________

Please make checks payable to GalaxSea Cruises & Tours.

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 documents@galaxseaonline.com Or Fax to 417-451-9120