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Your Information
Name: ___________________________________________________
Address: _________________________________________________
City: _____________________________________________________
State: _______________________________ Zip Code: ____________
Daytime/Evening Phone: _____________________________________
E-Mail Address: ____________________________________________
Date of Birth: ______________ Passport Expiration: ______________
Name of the Tour: __________________________________________
[ ] Request for Single Supplement [ ] Roommate Available [ ] Request Roommate
Available Roommate Name: _________________________________________
SPECIAL Meals or Services Requirements: _____________________________ Please include list of medications
Emergency Contact 1: _____________________________Phone:___________
Emergency Contact 2: _____________________________Phone:___________
Amount of Deposit: $ __________________ per person
Payment [ ] Check [ ] Money Order [ ] Credit Card: [ ] American Express [ ] Visa [ ] MasterCard [ ] Discover
Card Number: _________________________ Exp Date: ____________
Verification Code: __________ (3 digit number located on back of card)
Signature: _____________________________ Date: _______________
Click print to print form and fill out form completely. If you have any questions please contact us at 248-237-4969 or tcatravelclub@aol.com. Make all checks or money orders payable to: TCA Travel Club Inc. P.O. Box 44085, Detroit, Michigan 48244-0085. Your signature on this form acknowledges that you read and understand the terms and conditions page.
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