Clipper Travel Client Profile (* indicates mandatory fields)

Date*

Last Name*

First Name*

Title/Department

Company Name

I prefer to be contacted at work

I prefer to be contacted at home

Street (Work Address)

City/Town (Work Address)

Zip Code (Work Address)

Country (Work Address)

Work Phone incl. Area Code and Ext.

Work Fax incl. Area Code

e-mail Address*

Street (Home Address)

City/Town (Home Address)

Country (Home Address)

Phone Number incl. Area Code (Home)

Emergency Contact (Name and Phone)

> Frequent Flyer Mileage Program - Domestic American Airlines United Delta USAir Continental Northwest Southwest America West Alaska Air ATA None Yet Primary Mileage Carrier

> Frequent Flyer Mileage Program - Domestic American Airlines United Delta USAir Continental Northwest Southwest America West Alaska Air ATA None Yet Secondary Mileage Carrier

Primary Mileage Carrier/International

Secondary Mileage Carrie/International

Please fill in your travelling preferences

> Flight Seating Preferences Aisle Window Legroom is a priority No Preference > Smoking Preferences No Smoking Smoking

> Meal Preferences Diabetes Vegetarian - Asian Vegetarian - Indian/Muslim Vegan Gluten Free Kosher Cholesterol Lactose Low Calorie No Food Preference

other special needs (i.e. wheelchair, etc.)

Car Rental Preferences, please check your desired company

Alamo - Corp. Number

Avis - Wizard Number

Hertz - No.1 Club Number

Budget - Super Res Club 

National - Green Carpet

Thrifty

Dollar

Other

Car Rental Preferred Size (please check)

Economy Compact Mid-Size Standard Full Luxury

Manual Automatic Mini-Van

Hotel Programs

Holiday Inn Hyatt Ramada Marriott Sheraton Hilton

Best-Western Days Inn Westin Omni

Other

Preferred Bedding (allergies, etc.)

Preferred Room Type (please check)

Standard Superior Deluxe Suite

Credit Card Information

(please indicate if this is a debit card and if possible please give a back-up card)

Master Card Expire Date

Visa Expire Date

American Express Expire Date

Discover Expire Date

Diner's Club Expire Date

Carte Blanche Expire Date

Other Expire Date

Cardholder Name

Company Name (if on card)

For charge authorization, we will fax you the necessary forms.

If there is any other information that we should know to make your travel more comfortable, please let us know: