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Ms.
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*Last Name: |
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*Zip Code: |
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Eve Phone: |
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| *E-mail: |
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Birth Date: |
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| Country of Citizenship |
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| FORM OF PAYMENT: Credit
Card
Check:
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| Credit Card Type: |
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Card Number: |
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| Expiration Date: |
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If paying by check, please provide the following information: |
Check Number: |
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| Air Gateway City. Please specify: |
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Air Gateway State: |
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| No Air Required: |
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Mr.
Mrs.
Ms.
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| First Name: |
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Last Name: |
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| Mailing Address: |
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City: |
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| State: |
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Zip Code: |
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| Day Phone: |
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Eve Phone: |
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| E-mail |
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Birth Date: |
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| Country of Citizenship |
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| FORM OF PAYMENT: Credit
Card
Check:
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| Credit Card Type: |
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Card Number: |
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| Expiration Date: |
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If paying by check, please provide the following information: |
Check Number: |
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| Air Gateway City. Please specify: |
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Air Gateway State: |
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| No Air Required: |
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Mr.
Mrs.
Ms.
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| First Name: |
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Last Name: |
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| Mailing Address: |
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City: |
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| State: |
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Zip Code: |
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| Day Phone: |
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Eve Phone: |
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| E-mail |
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Birth Date: |
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| Country of Citizenship |
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| FORM OF PAYMENT: Credit
Card
Check:
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| Credit Card Type: |
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Card Number: |
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| Expiration Date: |
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If paying by check, please provide the following information: |
Check Number: |
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| Air Gateway City. Please specify: |
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Air Gateway State: |
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| No Air Required: |
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Mr.
Mrs.
Ms.
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| First Name: |
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Last Name: |
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| Mailing Address: |
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City: |
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| State: |
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Zip Code: |
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| Day Phone: |
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Eve Phone: |
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| E-mail |
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Birth Date: |
/
/
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| Country of Citizenship |
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| FORM OF PAYMENT: Credit
Card
Check:
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| Credit Card Type: |
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Card Number: |
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| Expiration Date: |
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If paying by check, please provide the following information: |
Check Number: |
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| Air Gateway City. Please specify: |
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Air Gateway State: |
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| No Air Required: |
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| Number of Passengers in your cabin *: 1
2
3
4
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Other passengers not in your cabin, with whom you would want to dine with or have cabins located close by (*WE WILL DO EVERYTHING POSSIBLE TO PUT CABINS IN PROXIMITY, BUT CANNOT GUARANTEE PLACEMENT IN EITHER CABINS, DINNER SEATING, OR AIRLINE SCHEDULE): |
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TYPE OF CABIN *:
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| DINING *: EARLY
LATE:
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TABLE SIZE: S
M
L
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| Medical Conditions: Wheelchair
Diabetes
Other
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***Valid passports are required!***
Optional Insurance Highly Recommended
Travel Insurance. We strongly urge you to protect your investment. Cancellation penalties apply! We will send you a Travel Guard Insurance form for you to fill out and mail directly to Travel Guard upon our receipt of your cruise deposit. Or you can signup IMMEDIATELY here online at TRAVEL GUARD INSURANCE
IMPORTANT
BY PLACING MY E-SIGNATURE BELOW, I HEREBY AUTHORIZE THE ABOVE CREDIT CARD TO BE CHARGED FOR THE CRUISE PACKAGE I HAVE PURCHASED.
BY SUBMITTING THIS ON-LINE APPLICATION I ACKNOWLEDGE THAT I UNDERSTAND I (WE) MUST BRING PROPER PROOF OF CITIZENSHIP AS REQUIRED BY THE GOVERNMENT AS DESCRIBED ON THE WEB SITE FOR THIS CRUISE, OR I (WE) WILL NOT BE ALLOWED TO BOARD THE SHIP AND NO REFUND WILL BE ISSUED.
IF YOU ARE MAILING A CHECK, PLEASE MAKE IT PAYABLE TO AND MAIL TO:
FLYING DUTCHMEN TRAVEL
2245 Montgomery Drive, Ste A
Santa Rosa, CA 95405
information@flyingdutchmentravel.com
707-546-1212
Please confirm your cruise request by filling out the e-signature and validation information below. Then click the SUBMIT button to complete your request. |
* VALIDATION CODE: Please type the numbers that you see:

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| *My Name: |
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| * Would you like to purchase Travel Insurance? Please type YES or NO: |
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| *Todays' Date: |
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