TRAVELER # 1 *

NAME AS SHOWN ON PASSPORT

First Name

Last Name

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact Number *

(###)

###

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TRAVELER # 2 (IF APPLICABLE)

Please fill in the fields below if you have an additional traveler (NAME AS SHOWN ON PASSPORT)

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

CONSENT 1 - TRAVEL REQUIREMENTS AND RESPONSIBILITIES *

Airlines (Domestic & International): A-Custom Travel acts solely as the agent for this vacation and is not responsible for the performance of any airline(s).  Tour Operator: The designated tour operator is the primary service provider responsible for on-the- ground arrangements including accommodations, excursions, transportation, and related travel services.  Travel Insurance: Travel insurance is not included in your package. It is strongly recommended to protect your investment.  Traveler Responsibility: Clients are solely responsible for meeting all entry and exit requirements for the United States and any countries included in their itinerary. This includes but is not limited to: o Valid passports o Visa applications o Vaccinations and medical clearances o Compliance with all travel advisories and regulations Failure to comply with any of the above may result in denied boarding, refusal of entry, or trip cancellation, for which no refunds may be issued. Travelers must also respect local laws and customs while abroad.

I HAVE READ, UNDERSTAND, AND AGREE WITH THE ABOVE INFORMATION

CONSENT 2 - DISCLAIMER OF LIABILITY *

I/We confirm that we have read and understand all information provided in this document. I acknowledge that:  A-Custom Travel has acted in good faith to assist in securing travel arrangements.  The agency does not guarantee nor accept liability for services provided by third-party suppliers (e.g., airlines, hotels, tour operators).  A-Custom Travel is not liable for cancellations, delays, or disruptions outside of its control.  I/We are solely responsible for obtaining and carrying all required travel documentation.  A-Custom Travel has advised us to consult www.travel.state.gov for the most current travel requirements.

I HAVE READ, UNDERSTAND, AND AGREE WITH THE ABOVE INFORMATION

ROOM ACCOMMODATIONS *

choose one

I have a roommate

I do NOT have a roommate and understand there is no discounted rate

PASSPORT STATUS *

choose one

I/We have a valid passport and have submitted it to A-Custom Travel

I/We have a passport pending

TRAVEL INSURANCE *

choose one

I/We have or will purchase travel insurance

I/We will NOT purchase travel insurance and accept full responcibilty

MEDIA CONCENT *

I/We agree to allow ACT to use photographs or videos taken during this trip for marketing and promotional purposes (choose one)

Yes

No

AGREEMENT AND SIGNATURE *

Please type your full legal name and date to comfirm your agreement to the terms outlined above

First Name

Last Name

Date *

Date of Acknowledgement

MM

DD

YYYY