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Travel Preference Form

If you complete this form you will recieve a complimentary ticketing fee waiver. Please fill in the form as completely as possible. The more information you give us, the better able we will be able to serve you. However, feel free to skip any part of this request form that does not apply to you. You can be assured that a travel consultant will contact you within 24 hours!!!

Primary Contact Information (Required)

Name

Legal Last Name

Legal First Name

I verify this is how my name appears on my passport or my driver's license. (Because the airlines verify the name on the ticket against your legal identification, the two names must be identical.)

Date of Birth:

Month:

Day:

Year:

Email & Phone Number

Email Address:
Primary Phone: (cell or home phone number is fine)

Mailing Address

Street:
City:
State:
Zip:

Drivers License Information (Required)

Name on Driver's License::
Issuing State:

Additional Contact Information

Street Address (if different than mailing address)

Street Address:
City:
State:
Zip:

Home Address (if different than mailing or street address)

Street Address:
City:
State:
Zip:

Email & Phone

Company Name (if applicable)
Business Phone:
Additional Phone:
Fax Number:

Alternate / Emergency Information (Spouse, Secratary etc.)

Name, Phone & Email, etc.

Name:
Phone:
Email Address:
Business Phone:
Home Phone:
Cell Phone:
Fax Number:

Airline Preference Information

Preferred Airline
Frequent Flyer Number:	*Pin:

Secondary Preferred Airline
Frequent Flyer Number:	*Pin:

Other Airline
Frequent Flyer Number:	*Pin:

Other Airline
Frequent Flyer Number:	*Pin:

Other Airline
Frequent Flyer Number:	*Pin:

* In order for Premier Travel to assist you with the issuance of free tickets using your frequent flyer miles we would need your frequent flyer personal id #.

Seat Assignment Preference

Location

Side of Plane:

Area of Plane:

In the event exit row seating is available, I confirm that I am exit row qualified. (Exit row qualified means you are at least 15 years old, can speak English, you are able to lift 55 pouonds and do not require a seat belt extension.)

Special Meal Requests

*If available PremierTravel will request special meals

Primary Request:	If 'Other' selected, specify below:
Secondary Request:	If 'Other' selected, specify below:

Other Special Needs

*Smoking Preference:
*Usually all flights are non-smoking
Special Needs:

Wheelchair Assistance:
	No assistance required
	I need assitance with long distances, but can walk to my seat on the plane.
	I need the above and cannot climb steps, but can make it to my seat.
	I need assistance all the way to my seat on the plane.

Other Needs:

Hotel Preference Information

Preferred Hotel Chain
Hotel Frequent Guest # :	Pin:

Secondary Preferred Hotel Chain
Hotel Frequent Guest # :	Pin:

Other Preferred Hotel Chain
Hotel Frequent Guest # :	Pin:

Other Preferred Hotel Chain
Hotel Frequent Guest # :	Pin:

Other Preferred Hotel Chain
Hotel Frequent Guest # :	Pin:

Rental Company Preference Information

Preferred Car Rental Company
Express Service ID:	Corporate Rate Code:

Secondary Preferred Car Rental Company
Express Service ID:	Corporate Rate Code:

Other Preferred Car Rental Company
Express Service ID:	Corporate Rate Code:

Other Preferred Car Rental Company
Express Service ID:	Corporate Rate Code:

Other Preferred Car Rental Company
Express Service ID:	Corporate Rate Code:

Car Preference information:

Vehicle Type & Smoking Preference

Vehicle Type:
Smoking Preference:

Car Location Preferences:

	Airport Location Only (if available)
	Short Shuttle Ride Okay (if much less costly)
	Shuttle Okay (if at all cheaper)

Car Amenity Preferenences:

	Must have navigational system
	Must have satellite radio system

Other Special Car Needs:

Passport Information

Do you have a passport?

YES

Name on Passport
Issuing Country:
Passport Number:
Expiration Date:

Would you like assistance in obtaining a passport?

	Yes
	No

Thank you for filling out this form. Please double check the information you entered and then press the 'submit' button below. We will contact you shortly.