Departure Date:_______________ Return Date:______________________

Address:__________________________________________________________

City, State:_____________________________________Zip:________________

Home Phone:_______________________ Work Phone:____________________

Email:_____________________________________________________________

Person traveling with if not listed above:__________________________________

Room selection (if applicable): ____Single ____Double/Twin ____Triple

Additional requests:_________________________________________________

I/we wish to purchase trip cancellation and interruption insurance. ___ Yes ___ NO

Deposit or Payment amount found in the Conditions section of your tour

Enclosed is a check for my payment or deposit in the amount of $_________.

Please charge my credit card in the amount of $__________.

Credit Card Number: ________________________________ Expires:______/______

Card Holder Name (please print):______________________________________

Signature:___________________________ Mastercard or Visa ONLY

Make checks payable and mail to : Call or email for additional info.

96 Ridgedale Ave ● Cedar Knolls, NJ 07927 973-538-1700 ● fax 973.292.1028 info@longstravel.com ● www.longstravel.com