NETHERLANDS LIBERATION ANNIVERSARY 2005
...........................
Enter your Last and First Name below (as it appears in your passport)
1.______________________________________________________________________
Title Last Name:
First:
2.______________________________________________________________________
Title Last Name:
First:
____________________________________________________________________________
____________________Address:
Apt. #
____________________________________________________________________________
____________________
Town
Province Postal Code
_________________________ ____________________________
_________________________
Home Phone: Bus. Phone or Fax:
(indicate which) E - mail:
Previous Liberation Celebration Experience? None Thank You Canada
Welcome Again Veterans
Please cross-reference me with the following friends who are traveling:
______________
....................................
Veteran Information: Name of Veteran
_________________________________
________________ __________________ _______________
_______________
Service Number Unit
Division Rank on Discharge
................................................
Special Needs:
1. Diet: _____________________ Wheelchair No/Yes, For distance/stairs
No/Yes, Must be carried to seat No/Yes
2. Diet: _____________________ Wheelchair No/Yes, For distance/stairs
No/Yes, Must be carried to seat No/Yes
Medical Information: 1_____________________________
2______________________________
................................................
Emergency Contact in Canada:
________________________________________________________________________
Last Name: First:
Relationship
____________________________________________________________________________
____________________
Town Province
Home Phone Bus. Phone
................................................
If you choose not to purchase the offered insurance you must sign and date
the waiver below! I, the undersigned, have refused the purchase of insurance
offered by Trafalgar Tours and therefore, will not hold Trafalgar Tours
responsible for any penalties or expenses incurred if I have to cancel or
become ill on the trip.
____________________________________
___________________________________
Signature
Date ................................................
Deposit Information:
Tour Deposit
$350.00 x ______ passengers = ___________
Insurance Passenger 1 $ ______ x 1
= ___________
Insurance Passenger 2 $ ______ x 1
= ___________
Total Deposit = ___________
Payment by: Cheque Payable to Fairlawn Travel Credit
Card Fill out information below
Credit Card Information: (if applicable)
____________________________________________
____________________________
Type of Card Card Number
Expiry Date
$____________________
____________________________
Amount of Deposit
Signature
Payment Schedule: Deposit: $350.00 per person deposit at the
time of booking plus your
insurance payment, credit card and trip extension fee if applicable.
Balance Due: March 15, 2005
Application Date: ____________________ Signature: ____________________
Mail booking form and deposit information to:
FAIRLAWN TRAVEL
104 - 117 Centrepointe Drive
Nepean, Ontario
K2G 5X3
(613) 723-9223 Phone
(613) 723-9285 Fax