Please fax this form to (425) 657-1901 (Please see note on page 2)
• Fax to Attention: ELIA SAEZ – 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.
• Final Payment due: 7/05/2012; Penalties begin 7/18/2012
• Additionally, mail the completed form to RHANW - 11320 SE Lincoln St, Portland, OR 97216
Names and dates of birth (must be first and last legal names only)
**Names must match passport (EXCEPT no middle names) or required documentation as stated on www.travel.state.gov **
LAST NAME, FIRST NAME GENDER Date of Birth PAST GUEST NUMBER U.S. Citizen?
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________
4. ________________________________________________________________________________
Cabin Category: ____________________________________________________________________
Special Request: (cabin near another group member, handicap room, special occasion, special needs,
pregnancy, etc.):
_________________________________________________________________
Deposit Amount: $250 per person
Cardholder Name: ___________________________________________________
Billing Address: ____________________________________________________
____________________________________________________
Telephone Number: _____________________________Home or Cell (circle one)
email address:______________________________________________________
Would you like to purchase Trip Protection? Yes____________ No_______________
Amount authorizing to charge: _____________________
Credit Card Number: ________________________________ Exp Date: __ / ___
(American Express, Visa or Master Card only)*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.
RED HAT ADVENTURES NW
7 Night New England/Canada Cruise - Norwegian Cruise Lines - Norwegian Dawn
Departing from: Boston, MA Departing date: October 5, 2012
Group Leaders: Lise Thom (503) 252-7670 – lisethom@aol.com
Jean Mounsey (360) 904-0332 - j.mounsey@comcast.net
www.redhatadventuresnw.com
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CABIN REQUEST DEPOSIT FORM
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Costco Travel’s Trip Protection:
• To book call Travel Guard at 1-888-691-2173 and provide Costco membership number, Group
Reference #C111222333, destination, ship name, sailing date & cost per person.
• Must be purchased PRIOR to final payment for pre-existing conditions waiver
• Valid for purchase by US Residents only.
• Trip Protection Coverage – go to www.costcotravel.com at bottom of page select Trip Protection.
FAXING YOUR CABIN REQUEST:
Please be advised that your fax comes over our secure phone lines and can only be viewed by the
groups department. We treat your personal information with the utmost care. Your email address
and/or phone number will be used only if we have a specific question regarding your request. Please
do not email credit card information for your own personal protection.