Thank you for your booking information!

Below is a summary of the information you provided. You may wish to print this page as a reference.

Passenger Name/s – as it appears in your passport

Pax	Prefix	First Name	Middle Name	Surname	Preferred Name	Date of Birth
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2
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4

Contact Details

Email:
Address:



Home Phone:
Work Phone:
Mobile Phone:

Memberships

Pax	Program	Membership No.	Program	Membership No.
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2
3
4

Passports

Pax	Passport Number	Date of Issue	Date of Expiry	Nationality
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2
3
4

Special Requests

Travel Insurance

Please note that Exclusively Cruising can only offer general advice regarding travel insurance. We recommend that you read the PDS brochures for each quotation that will be emailed to you with your quotation. If you require further information after reviewing the PDS, we would suggest that you contact the customer service number provided with the quotation for each company Exclusively Cruising can only base your travel insurance quote on the information provided to us.

Quote for travel insurance:

Insurance Company Name:
Policy Number:
Insurance Emergency Contact Number:

Emergency Contact Information

Pax	Emergency Contact Name	Relationship to Passenger	Address	Daytime Phone Number	Email
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NOTE: Due to the Privacy Act (1988), in an emergency situation or if you become injured and/or sick we may be required to pass on your personal details and emergency contact details to authorities such as DFAT or emergency services. If you can please confirm your permission:

Yes, please pass my details on in an emergency:

Additional Comments and Information

Terms and Conditions

Date: