RED HAT ADVENTURES NW
4 Night Baja Mexico Cruise – Paradise
Departing from: Long Beach, California
Group Leaders: Lise Thom (503) 252-7670, lisethom@aol.com
Jean Mounsey (360) 904-0332, j.mounsey@comcast.net
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• Please fax this form to (425) 657-1901 no later than JULY 23, 2010
• Fax to Attention: STACY MEZA - Costco Travel Groups Department
• Please fill out one form for each cabin.
• If more than one credit card, per cabin, is being used fill out separate forms and note persons who are
sharing the cabin.
Names (must be full legal first and last name only)
**Passports are required for all passengers. Names must match passport. Middle names or initials are
not used**
LAST NAME, FIRST NAME
1. ____________________________________________________
2. ____________________________________________________
3. ____________________________________________________
4. ____________________________________________________
Cabin Number: ______________________
Insurance requested? Yes________ No___________
Credit Card Information: Visa MasterCard American Express
Is your card a debit card? Yes* No
*Special note on debit cards: debit cards have maximum daily limits; please verify with your bank that
the dollar amount being charged can be processed in one transaction.
Cardholder Name:______________________________________
Billing Address:________________________________________
______________________________________________________
Telephone Number: ______________________Home or Cell (circle one)
Amount authorizing to charge: _____________________
Credit Card Number: ____________________________ Exp Date: __ / ___