Lizzy McCartney • D.B.A. • Travel With Lizzy, L.L.C.

15 Union Street • Cortland, New York 13045 USA

lizzy@indytravelforwomen.com

WHICH TRIP ARE YOU RESERVING? -----
India
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Personal Info *Required Passport Info
Name (Exactly as it appears on passport.)  
First Name: Passport Number:
Middle Name: Country of Issue:
Last Name: Date of Issue:
  Date of Expiration:
Address Redress Number:
If applicable. For more info please visit DHS
Address line 1:  
Address line 2:  
City: Homeland Security *Required
State / Province / Region: Date of Birth:
Postal Code:  
 
Contact Information
Cell Phone Number:
Email Address:

Travel Info Emergency Contact
Allergies: Name:
Dietary Needs: Relationship:
Seating Preferences: Cell Phone Number:
Do you use a wheelchair?
No Yes
Other Special Needs:

Insurance
By checking this box I am affirming that I understand I must have travel insurance that meets the requirements set forth in the brochure for this I.N.D.Y. Travel Society adventure. I further understand that I will have to show proof of insurance prior to departure. Failure to supply proof of the required travel insurance will result in the cancellation of my participation in the tour without refund.
Would you like information on the optional travel insurance being offered with this tour? Yes No