Cross Continental Travel, Your Educational Travel and Travel For Credit Specialist!

Literary, Natural & Historical Landscapes Tour of Britain, Wales & Ireland with Optional Scotland Extension

Personal Data

Legal Name
(as it appears on your passport)

Mailing Address

City, State Zip

Home Telephone

Are you a US citizen?
Yes No

Date of Birth
(MMDDYY)

Male Female

Passport #

Country of Issue

Spouse or roomate's name
(as it appears on their passport)

Roommate's Mailing Address

Roommate's City,State Zip

Roommate's Home Telephone

Roommate's Email

Is your Roommate a US citizen?
Yes No

Roommate's Date of Birth (MMDDYY)

Male Female

Roommate's Passport #

Country of Issue

Emergency Contact Person (Not travelling with you)

Your Contact Name

Relationship to you

Address

City, State, Zip

Home Telephone

Work Telephone

Room mate contact name (If different from yours)

Relationship to roommate

Address

City, State, Zip

Home Telephone

Work Telephone

Travel Data

Accommodations: Twin Double Single
Program fee based on double occupancy
A Single will incur additional charges, inquire.

Additional Excursions: London Theatre Tickets Irish Cultural Night-Approximately $25 per event
Scotland Extension, $1500

Initial Trip Cost	$3350
Scotland Extension ($1500)
Other Costs (i.e. single room occupancy)
Total

Payment

Make all checks payable to Cross-Continental Travel and mail to:
Donna Frazer-Palmer/Cross-Continental Travel
34 Wright Court
Lakewood, CO 80228

Timetable
Call

Release and Agreement

Don't forget to "sign" and submit your application.
By submitting this application you agree that you have read and fully understand the "Release and Agreement" and the "Booking Conditions" as supplied herewith, and agree to be bound hereby, and to comply therewith.

Signature Date

For information call (303) 988-5304 | cell (303) 519-9119 | fax (303) 988-5271 or email donna@crosscontinentaltravel.com.