Phone: (417) 451-5468 | Email:

RESERVATION FORM KSN TV / Jim Jackson 2017 Southern Caribbean Cruise October 12 – 21, 2017

PLEASE PRINT, complete, and mail, with deposit

or email info to ken@galaxseaonline.com and call with payment information

 

Passenger Name(s)                                                     Date of Birth     Gender             Daytime Telephone

(Name spelling should match your passport/driver’s license)

 

1._______________________________________     ___________            _______          _________________

 

2._______________________________________     ___________            _______          _________________

 

Mailing Address: _____________________________________________________________________________________

 

Home Phone: _________________Work Phone: _________________ Cell Phone: __________________

 

Email Address: _____________________________________ Home or Work

 

Room Type Requested ___________________________________ (Inside, Ocean View, or Balcony)

 

Are you sharing your room with anyone not listed above?

 

__________________________________________

 

Dinner Time (circle one):                      6:00pm            8:00pm            Your Choice Time

 

Travel Insurance (Yes or No)   ________________

 

Amount Enclosed:       Package 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 REQUESTS

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

__________________________________________________________________________________________

 

COMPLETE AND MAIL WITH DEPOSIT TO:

GalaxSea Cruises & Tours, 210 N. Business 49

Neosho, MO 64850

Or Fax to 417-451-9120